Nokea
A nurse is preparing to administer 17,000 units heparin subcutaneously. Available is heparin 20,000 units/mL. How many mL should the nurse administer? (Round the answer to the nearest hundredth. Use a leading zero if applicable. Do not use a trailing zero.)
- A. 0.85
Correct Answer: A
Rationale: To calculate the mL of heparin needed, use the formula: Amount needed (17,000 units) ÷ Concentration of heparin (20,000 units/mL) = mL to administer. 17,000 ÷ 20,000 = 0.85 mL (Round to the nearest hundredth). Therefore, the correct answer is A (0.85 mL). Other choices are incorrect as they do not result from the correct calculation.
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A nurse is administering the first dose of ramipril to a client who has hypertension. The client reports feeling dizzy and lightheaded. Which of the following should the nurse administer?
- A. 15 g of carbohydrates
- B. Naloxone
- C. Diphenhydramine
- D. Fluid bolus
Correct Answer: D
Rationale: The correct answer is D: Fluid bolus. The client is experiencing symptoms of hypotension, a common side effect of ramipril. Administering a fluid bolus helps increase blood volume, improving blood pressure and alleviating dizziness and lightheadedness. It is important to address the underlying cause of the symptoms. Choices A, B, and C are not appropriate in this situation as they do not address the hypotension caused by ramipril. Administering carbohydrates (A) is irrelevant, naloxone (B) is used for opioid overdose, and diphenhydramine (C) is an antihistamine and not indicated for hypotension.
A nurse is reinforcing teaching with a client who has a new prescription for nitroglycerin transdermal patches to treat angina. The nurse should inform the client that which of the following manifestations is an adverse effect of the medication?
- A. Headache
- B. Polyuria
- C. Ringing in the ears
- D. Increased blood pressure
Correct Answer: A
Rationale: The correct answer is A: Headache. Nitroglycerin transdermal patches can cause headaches as an adverse effect due to vasodilation leading to increased blood flow to the brain. This is a common side effect that may occur in patients using nitroglycerin. Polyuria (B) and ringing in the ears (C) are not common side effects of nitroglycerin. Increased blood pressure (D) is not an adverse effect of nitroglycerin; in fact, nitroglycerin decreases blood pressure by dilating blood vessels.
Vital Signs
Nurses' Notes
History and Physical
Initial visit:
Temperature 36.5° C (97.7° F)
Heart rate 68/min
Blood pressure 116/70 mm Hg
Respiratory rate 16/min
SpO2 98% on room air
Follow-up visit 2 weeks later:
Temperature 36.7° C (98.1° F)
Heart rate 86/min
Blood pressure 130/80 mm Hg
Respiratory rate 18/min.
SpO2 99% on room air
Select the 6 statements the nurse should include when reinforcing teaching to the client about the newly prescribed medication.
- A. This medication should start to alleviate the headache within 1 hour.
- B. You might experience a feeling of pressure in your chest after taking this medication.
- C. Do not take more than 200 milligrams of this medication within 24 hours.
- D. You can take a second dose of this medication at least 2 hours after the initial dose if the headache persists.
- E. You should discontinue this medication if pregnancy is planned or suspected.
- F. This medication can cause you to feel tired.
- G. You might experience a rash on your skin while taking this medication.
Correct Answer: A,B,C,D,E,F
Rationale: The correct answer includes statements covering various important aspects of the medication. A: Ensures client knows when to expect relief. B: Alerts to potential side effect. C: Provides clear dosing instructions. D: Instructs on when and how to take a second dose. E: Important for safety during pregnancy. F: Warns about potential side effect. Explanations for incorrect choices: G: Not as crucial as the other statements.
A nurse is preparing to administer erythromycin PO to a client who has an infection. The nurse checks the client's medical record and notes that the client has a severe allergy to penicillin. Which of the following actions should the nurse take?
- A. Request a different medication from the provider.
- B. Premedicate the client with diphenhydramine.
- C. Administer the medication to the client.
- D. Request a different route of administration from the provider.
Correct Answer: C
Rationale: Rationale: The correct action is to administer the medication to the client (Choice C) because erythromycin is not related to penicillin and is safe to use in clients with a penicillin allergy. Requesting a different medication (Choice A) may not be necessary as erythromycin is a suitable alternative. Premedicating with diphenhydramine (Choice B) is not indicated for a penicillin allergy. Requesting a different route of administration (Choice D) is unnecessary since the oral route is appropriate for erythromycin.
A nurse is caring for a client who has a new prescription for a nitroglycerin transdermal patch. Which of the following actions should the nurse take?
- A. Take the patch off prior to bathing the client.
- B. Monitor for hypertension after application of the patch.
- C. Rotate the application sites of the patch.
- D. Remove the patch every 24 hr
Correct Answer: C
Rationale: The correct answer is C: Rotate the application sites of the patch. This is important to prevent skin irritation and tolerance development. By rotating the sites, the nurse ensures consistent drug absorption and effectiveness. Choice A is incorrect because removing the patch prior to bathing can disrupt drug delivery. Choice B is incorrect as nitroglycerin typically causes hypotension, not hypertension. Choice D is incorrect as nitroglycerin patches are usually left on for 12-14 hours and then replaced with a new patch.