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A nurse is monitoring a client who received naloxone to counteract the effects of an opioid overdose. Which of the following findings should indicate to the nurse that the medication is effective?
- A. Increased respiratory rate
- B. Report of decreased pain
- C. Increased temperature
- D. Decreased blood pressure
Correct Answer: A
Rationale: Correct Answer: A: Increased respiratory rate
Rationale: Naloxone is an opioid antagonist that reverses the effects of opioids, including respiratory depression. Therefore, an increased respiratory rate indicates that naloxone is effectively reversing the opioid overdose by restoring normal breathing patterns. Monitoring the respiratory rate is crucial in assessing the effectiveness of naloxone and ensuring the client's safety.
Incorrect Choices:
B: Report of decreased pain - Naloxone does not directly affect pain perception.
C: Increased temperature - Naloxone does not typically cause changes in body temperature.
D: Decreased blood pressure - Naloxone may cause a transient increase in blood pressure due to its effects on the sympathetic nervous system, but this is not the primary indicator of its effectiveness.
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A nurse is reinforcing teaching with a client who has a new prescription for prednisone to treat rheumatoid arthritis. Which of the following statements should indicate to the nurse that the client understands the teaching?
- A. I should watch for weight loss.
- B. I should increase the sodium in my diet.
- C. I will take this medication on an empty stomach.
- D. I will report a sore throat to my provider.
Correct Answer: D
Rationale: The correct answer is D: "I will report a sore throat to my provider." This is the correct answer because prednisone can suppress the immune system, increasing the risk of infections like thrush or sore throat. Reporting these symptoms promptly is crucial to prevent complications.
Choice A is incorrect because prednisone can actually cause weight gain. Choice B is incorrect because prednisone can lead to fluid retention, so increasing sodium intake is not recommended. Choice C is incorrect because prednisone should be taken with food to reduce stomach upset.
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. Use the Z-track technique to administer the medication.
- B. Administer the medication with a 27-gauge 1/2-inch needle.
- C. Inject the medication at least 5 cm (2 in) from the umbilicus.
- D. Give the medication without aspirating prior to injection.
Correct Answer: A
Rationale: The correct answer is A: Use the Z-track technique to administer the medication. This technique helps prevent leakage of the medication into surrounding tissues by sealing the medication in the muscle. The Z-track method involves pulling the skin laterally before injecting the medication, then releasing the skin after the injection. This creates a zig-zag path that closes after the needle is withdrawn, reducing the risk of irritation or staining at the injection site. Choice B is incorrect because the needle size for IM injections in adults is typically 22-25 gauge and 1-1.5 inches long. Choice C is incorrect as IM injections should be administered at least 2.5 cm (1 inch) away from the umbilicus. Choice D is incorrect because aspiration (pulling back on the plunger to check for blood return) is not recommended for IM injections due to the risk of tissue trauma.
A nurse is preparing to administer enoxaparin 5 mg/kg subcutaneous daily to a client who has deep-vein thrombosis. The client weighs 152 lb. Available is 120 mg/0.8 mL prefilled syringe. Calculate the dosage in mL that the nurse should administer. (Round the answer to the nearest tenth. Use a leading zero if applicable. Do not use a trailing zero.)
- A. 0.7
Correct Answer: A
Rationale: To calculate the dosage in mL, first convert the client's weight from pounds to kilograms: 152 lb ÷ 2.2 = 69.1 kg. Then, multiply the weight by the dose (5 mg/kg): 69.1 kg x 5 mg/kg = 345.5 mg. Next, determine the volume needed by dividing the dose by the concentration (120 mg/0.8 mL): 345.5 mg ÷ 120 mg/0.8 mL = 2.3 mL. Round to the nearest tenth, giving 2.3 mL. The correct answer is A (0.7 mL) because 2.3 mL is incorrectly rounded. Other choices are incorrect due to incorrect calculations or rounding.
A nurse is collecting data from a client who has been taking carbamazepine. Which of the following is an adverse effect of carbamazepine and should be reported to the provider?
- A. Sore throat
- B. Increased salivation
- C. Urge incontinence
- D. Gingivitis
Correct Answer: A
Rationale: The correct answer is A: Sore throat. Carbamazepine can cause agranulocytosis, a serious condition characterized by a decrease in white blood cells, leading to symptoms like sore throat. This is a potentially life-threatening adverse effect that should be reported to the provider immediately. Increased salivation (choice B), urge incontinence (choice C), and gingivitis (choice D) are not common adverse effects of carbamazepine and do not require immediate reporting.
A nurse is reinforcing discharge teaching about sublingual nitroglycerin with a client who has angina. Which of the following statements indicates an understanding of the instructions?
- A. I understand that the medication can slow my heart rate.
- B. I am going to take the medication with food.
- C. I will take the medication every 10 minutes until the pain goes away.
- D. I should feel the effects of the medication within 5 minutes.
Correct Answer: D
Rationale: Correct Answer: D
Rationale: Nitroglycerin is a fast-acting medication used to relieve angina symptoms. Choosing option D shows understanding because nitroglycerin should provide relief within 5 minutes if the medication is effective. This rapid onset is crucial in managing acute angina attacks. Taking the medication every 10 minutes (C) could lead to overdose and severe side effects. Slow heart rate (A) is not a common side effect of nitroglycerin. Taking with food (B) may delay absorption and reduce effectiveness.