Nokea
A nurse is planning care for a client who has angina and a new prescription for nitroglycerin ointment. Which of the following actions should the nurse plan to take?
- A. Cover the administration area with plastic wrap.
- B. Massage the ointment into the skin.
- C. Spread the ointment in a 10 cm2 (4in2) area.
- D. Apply the ointment in a thick layer.
Correct Answer: A
Rationale: The correct answer is A. The nurse should cover the administration area with plastic wrap when applying nitroglycerin ointment to prevent accidental exposure to others and to ensure proper absorption of the medication. This step helps to enhance the drug's efficacy by promoting direct contact with the skin and preventing it from being rubbed off onto clothing or other surfaces. Massaging the ointment into the skin (B) may alter the absorption rate and distribution of the medication. Spreading the ointment in a 10 cm2 area (C) may lead to inaccurate dosing. Applying the ointment in a thick layer (D) may result in overdose or underdose due to inconsistent dosing.
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A nurse is caring for a client who is receiving a continuous IV infusion and reports pain at the IV insertion site. The nurse observes the arm is swollen and cool to touch. After discontinuing the infusion, which of the following actions should the nurse take next?
- A. Restart the infusion in other extremity
- B. Elevate the extremity
- C. Remove the catheter
- D. Apply warm, moist compresses to the site.
Correct Answer: B
Rationale: The correct answer is B: Elevate the extremity. By elevating the extremity, the nurse can help reduce swelling and improve blood flow to the area. This can help alleviate pain and prevent further complications. Removing the catheter (choice C) is necessary but not the immediate next step. Restarting the infusion in another extremity (choice A) can exacerbate the issue. Applying warm, moist compresses (choice D) may not be appropriate if there is swelling. Make sure to monitor the client for any signs of infection or other complications.
A nurse is reinforcing teaching with a client who has a new prescription for digoxin. Which of the following herbal supplements should the nurse include as a contraindication for this medication?
- A. Glucosamine
- B. Garlic
- C. St. John's wort
- D. Ginkgo biloba
Correct Answer: C
Rationale: The correct answer is C: St. John's wort. St. John's wort can decrease the effectiveness of digoxin, leading to reduced therapeutic effects. This is due to St. John's wort inducing the enzymes that metabolize digoxin, resulting in lower drug levels in the body. Glucosamine (A), garlic (B), and ginkgo biloba (D) do not have significant interactions with digoxin. It is important to educate the client about potential herb-drug interactions to ensure the safety and effectiveness of their treatment.
A nurse is collecting data from a client following the administration of a new medication. Which of the following findings should the nurse identify as a manifestation of an allergic reaction?
- A. Jaundice
- B. Urticaria
- C. Bradycardia
- D. Hypertension
Correct Answer: B
Rationale: The correct answer is B: Urticaria. Urticaria, also known as hives, is a common manifestation of allergic reactions. It presents as raised, red, itchy welts on the skin. Jaundice (A) is associated with liver dysfunction, not typically an allergic reaction. Bradycardia (C) is a slow heart rate and not a common allergic reaction symptom. Hypertension (D) is high blood pressure and is not typically associated with allergic reactions. Therefore, based on the symptoms of an allergic reaction, urticaria is the most appropriate choice.
A nurse is preparing to administer medications to a client through an enteral feeding tube. Which of the following interventions is appropriate?
- A. Add the medications to the enteral feeding bag.
- B. Check for gastric residual 15 min after administering the medications
- C. Keep the client's head elevated 15° while administering the medications.
- D. Flush the tube with 30 ml of water between each medication
Correct Answer: D
Rationale: The correct answer is D: Flush the tube with 30 ml of water between each medication. Flushing the tube with water between medications helps prevent clogging and ensures proper medication administration. It also helps prevent interactions between different medications. Adding medications to the feeding bag (choice A) may cause drug interactions or alter the efficacy of the medications. Checking for gastric residual 15 min after administering medications (choice B) is not necessary for enteral tube medication administration. Keeping the client's head elevated 15° (choice C) is important during feeding, but not specifically for medication administration.
A nurse is reinforcing teaching with a client who has a new prescription for lithium. Which of the following information should the nurse include in the teaching?
- A. Increase fluid intake
- B. Decrease sodium intake
- C. Eat foods high in potassium
- D. Take the medication 1 hr before meals.
Correct Answer: A
Rationale: The correct answer is A: Increase fluid intake. Lithium is a medication used to treat bipolar disorder, and it can cause dehydration and increase the risk of lithium toxicity. By increasing fluid intake, the client can maintain proper hydration levels, which helps to prevent lithium toxicity. This information is crucial for the client's safety and well-being.
Incorrect choices:
B: Decrease sodium intake - While monitoring sodium intake is important with lithium therapy, decreasing it is not necessary.
C: Eat foods high in potassium - While maintaining a balanced diet is important, focusing on potassium specifically is not directly related to lithium therapy.
D: Take the medication 1 hr before meals - Lithium can be taken with or without food, so the timing of meals in relation to medication is not a critical teaching point.