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A nurse is collecting data from a client who was taking oxycodone four times a day for chronic pain and reports discontinuing the medication 10 days ago. Which of the following findings should the nurse expect?
- A. Hypotension
- B. Constricted pupils
- C. Insomnia
- D. Constipation
Correct Answer: C
Rationale: The correct answer is C: Insomnia. When a client discontinues oxycodone, a narcotic analgesic, they may experience withdrawal symptoms such as insomnia due to the abrupt cessation of the medication affecting the central nervous system. Hypotension (A) is not typically a withdrawal symptom of oxycodone. Constricted pupils (B) are a sign of opioid intoxication, not withdrawal. Constipation (D) is a common side effect of opioid use but is not a typical withdrawal symptom in this scenario.
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A nurse is collecting data from a client who has been taking diazepam several times per day but recently ran out of the medication. Which of the following findings should the nurse recognize as a manifestation of withdrawal from diazepam?
- A. Hypotension
- B. Anorexia
- C. Tremors
- D. Drowsiness
Correct Answer: C
Rationale: The correct answer is C: Tremors. Diazepam is a benzodiazepine used for anxiety and withdrawal symptoms include tremors due to the sudden decrease in GABA activity. Hypotension (A) is not a typical withdrawal symptom of diazepam. Anorexia (B) is more commonly associated with stimulant withdrawal. Drowsiness (D) is a side effect of diazepam, not a withdrawal symptom.
A nurse is reinforcing discharge teaching with a client who has a new diagnosis of type 2 diabetes mellitus and a prescription for exenatide. Which of the following instructions should the nurse include in the teaching?
- A. Contact the provider if you experience unexplained muscle pain.
- B. Inject the medication into the subcutaneous tissue of your abdomen.
- C. Take the medication at bedtime.
- D. Discard excess medication after 60 days.
Correct Answer: B
Rationale: The correct answer is B: Inject the medication into the subcutaneous tissue of your abdomen. Exenatide is a medication used to treat type 2 diabetes and is administered by subcutaneous injection. Injecting it into the abdomen allows for better absorption. It is important for the nurse to instruct the client on the correct administration technique to ensure the medication is effective.
Incorrect choices:
A: Contact the provider if you experience unexplained muscle pain - Although monitoring for side effects is important, muscle pain is not a common side effect of exenatide.
C: Take the medication at bedtime - Exenatide is typically taken before meals, not at bedtime.
D: Discard excess medication after 60 days - Exenatide must be refrigerated and has a shorter shelf life once opened, typically 30 days, not 60.
A nurse is preparing to administer an IM injection to a client who has gonorrhea. Which of the following actions should the nurse take?
- A. Inject the medication at least 5 cm (2 in) from the umbilicus.
- B. Administer the medication with a 27-gauge /0.5 inch needle.
- C. Use the Z-track technique to administer the medication.
- D. Give the medication without aspirating prior to injection.
Correct Answer: C
Rationale: The correct answer is C: Use the Z-track technique to administer the medication. The Z-track technique involves pulling the skin laterally before injecting the medication to prevent leakage and irritation. This is crucial when administering IM injections to prevent the medication from leaking into the subcutaneous tissue. Option A is incorrect because the injection site for IM injections should be at least 2.5 cm (1 inch) away from the umbilicus. Option B is incorrect because a larger needle gauge (e.g., 22-25 gauge) is typically used for IM injections to reduce discomfort and prevent medication leakage. Option D is incorrect because aspirating prior to injection is not necessary for IM injections and may cause tissue damage.
A nurse is reinforcing teaching with a young adult client who has a new prescription for ear drops. Which of the following instructions should the nurse include?
- A. Chill the medication prior to instillation.
- B. Press a cotton ball firmly in ear canal after administering drops.
- C. Pull the pinna up and back to administer medication.
- D. Place an applicator into the ear canal to instill drops.
Correct Answer: C
Rationale: The correct answer is C: Pull the pinna up and back to administer medication. This instruction is correct because pulling the pinna up and back helps straighten the ear canal in adults, allowing the drops to be instilled properly. This technique ensures that the medication reaches the desired target area for optimal effectiveness.
Explanation of other choices:
A: Chilling the medication is not necessary and can cause discomfort to the client.
B: Pressing a cotton ball firmly in the ear canal can prevent the drops from reaching the ear canal.
D: Placing an applicator into the ear canal can cause injury or damage to the ear canal and eardrum.
A nurse is caring for a client who has a new diagnosis of schizophrenia. Which of the following medications should the nurse expect to administer?
- A. Levodopa
- B. Baclofen
- C. Fenofibrate
- D. Risperidone
Correct Answer: D
Rationale: The correct answer is D: Risperidone. Risperidone is an antipsychotic medication commonly used to treat schizophrenia by helping to manage symptoms such as hallucinations and delusions. Levodopa (A) is used for Parkinson's disease, Baclofen (B) is a muscle relaxant, and Fenofibrate (C) is used to lower cholesterol. Administering any of these medications to a client with schizophrenia would not address their symptoms effectively.