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A nurse is planning to administer a tuberculin skin test to a client who has had an exposure to tuberculosis. Which of the following actions should the nurse plan to take?
- A. Inject 0.3 to 0.5 mL of the solution.
- B. Select an injection site that is free of scar tissue.
- C. Hold the needle at a 30° angle during injection.
- D. Massage the site following the injection.
Correct Answer: B
Rationale: Correct Answer: B - Select an injection site that is free of scar tissue.
Rationale: Selecting an injection site that is free of scar tissue is crucial for accurate tuberculin skin test results. Scar tissue can interfere with the test by affecting the absorption of the solution and potentially leading to false results. Choosing a site free of scar tissue ensures proper administration and interpretation of the test.
Incorrect Choices:
A: Injecting 0.3 to 0.5 mL of the solution is not the key factor in ensuring accurate results. The volume to be injected may vary based on the specific test kit used, but the injection site's condition is more critical.
C: Holding the needle at a 30° angle is not a standard requirement for administering a tuberculin skin test. The angle of injection may vary based on the client's skin thickness and other factors.
D: Massaging the site following the injection is unnecessary and could potentially lead to inaccurate results. Massaging can alter the distribution
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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. Take the medication at bedtime.
- C. Discard excess medication after 60 days.
- D. Inject the medication into the subcutaneous tissue of your abdomen.
Correct Answer: D
Rationale: The correct answer is D: Inject the medication into the subcutaneous tissue of your abdomen. Exenatide is a medication that is administered through subcutaneous injection, typically into the abdomen. This is the correct route of administration to ensure proper absorption and effectiveness of the medication. Option A is incorrect as it is not directly related to the administration of exenatide. Option B is incorrect because exenatide is usually taken before meals, not at bedtime. Option C is incorrect as the disposal timeline for exenatide is typically shorter than 60 days.
A nurse is collecting data from a client who has been taking methimazole for 2 months for the treatment of a thyroid imbalance. Which of the following findings indicates that the medication is effective?
- A. Weight gain
- B. Decreased menstrual flow
- C. Clear breath sounds
- D. Increased libido
Correct Answer: A
Rationale: The correct answer is A: Weight gain. Methimazole is used to treat hyperthyroidism, which often causes weight loss due to increased metabolism. If the medication is effective, the client's thyroid hormone levels should normalize, leading to a potential reversal of weight loss and even weight gain. Decreased menstrual flow (B) and increased libido (D) are not direct indicators of methimazole effectiveness. Clear breath sounds (C) could indicate improved respiratory status but are not specific to thyroid function.
A nurse is caring for a client who started taking amitriptyline 6 days ago. The client reports that the medication is not helping. Which of the following responses should the nurse make?
- A. I will ask your provider to increase the dose of the medication.
- B. You will need to take this medication on an empty stomach for it to be more effective.
- C. You will need to wait a couple of weeks to feel the therapeutic effect of the medication.
- D. I will inform your provider so they can prescribe a different medication.
Correct Answer: C
Rationale: The correct response is C: "You will need to wait a couple of weeks to feel the therapeutic effect of the medication." Amitriptyline, a tricyclic antidepressant, typically takes 2-4 weeks to start showing its full therapeutic effects. It is important for the nurse to educate the client about the delayed onset of action to manage expectations. Option A is incorrect because increasing the dose prematurely can lead to adverse effects. Option B is incorrect as taking it on an empty stomach is not necessary for its efficacy. Option D is incorrect as switching medications without giving the current one a fair trial may not be appropriate.
A nurse is caring for a client who is receiving treatment for chronic alcohol use disorder. Which of the following medications should the nurse plan to administer to assist the client in maintaining abstinence by aversion therapy?
- A. Carbamazepine
- B. Disulfiram
- C. Atenolol
- D. Lorazepam
Correct Answer: B
Rationale: The correct answer is B: Disulfiram. Disulfiram is used in aversion therapy for alcohol use disorder by causing unpleasant effects like nausea, vomiting, and flushing when alcohol is consumed. This helps deter the client from drinking. Carbamazepine (A) is used for seizures, mood disorders, and neuropathic pain, not specifically for aversion therapy. Atenolol (C) is a beta-blocker used for hypertension and not for aversion therapy. Lorazepam (D) is a benzodiazepine used for anxiety and not for aversion therapy.
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. Tremors
- B. Anorexia
- C. Drowsiness
- D. Hypotension
Correct Answer: A
Rationale: The correct answer is A: Tremors. Diazepam is a benzodiazepine used to treat anxiety and withdrawal symptoms. Withdrawal from diazepam can lead to physical symptoms such as tremors due to the sudden decrease in the drug's effects on the central nervous system. Tremors are a common manifestation of benzodiazepine withdrawal. Anorexia (choice B) is not typically associated with diazepam withdrawal. Drowsiness (choice C) is more likely a side effect of diazepam itself, not withdrawal. Hypotension (choice D) is not a common withdrawal symptom of diazepam.