Nokea
A nurse is preparing to administer a daily dose of warfarin to a client. Which of the following laboratory values should the nurse check prior to administration?
- A. WBC
- B. INR
- C. Platelets
- D. APTT
Correct Answer: B
Rationale: The correct answer is B: INR. The International Normalized Ratio (INR) is a crucial laboratory value to monitor before administering warfarin, an anticoagulant. INR helps assess the effectiveness and safety of warfarin therapy by measuring the clotting time of blood. This ensures that the dose is within the therapeutic range to prevent clotting or bleeding complications. Checking white blood cells (WBC), platelets, or activated partial thromboplastin time (APTT) is not directly related to warfarin administration. WBC count indicates infection or inflammation, platelets assess clotting ability, and APTT evaluates the intrinsic pathway of coagulation. However, these values do not specifically guide warfarin dosing like the INR does.
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Nurses’ notes
Vital Signs
Medication Administration Record
Client reports tightness in the chest that radiates to the left arm. States pain as 7 on a scale of 0 to 10. Client is diaphoretic and short of breath.
Which of the following instructions should the nurse include when reinforcing teaching to the client about their medication? Select all that apply.
- A. Lie down with feet elevated if dizziness occurs while taking this medication.
- B. Apply the patch daily to a hairless area of the skin.
- C. The medication will be effective 30 to 45 min following application.
- D. Remove the patch 12 to 14 hr following application.
- E. Remove the patch if you experience a headache.
- F. Place the patch on the same area every day.
Correct Answer: A,B,D
Rationale: Correct answer: A, B, D
Rationale:
A: Instructing the client to lie down with feet elevated if dizziness occurs is important as it can prevent falls and injury.
B: Applying the patch to a hairless area of the skin ensures proper drug absorption and effectiveness.
D: Removing the patch after 12 to 14 hours prevents skin irritation and ensures the medication is not being overexposed.
Incorrect answer explanations:
C: The time frame given for medication effectiveness is inaccurate and may lead to confusion.
E: Removing the patch if experiencing a headache is not a standard instruction and may interfere with the medication's intended purpose.
F: Placing the patch on the same area daily can lead to skin irritation or decreased drug absorption due to buildup.
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
A nurse is reinforcing discharge teaching with a client who has a prescription for rifampin for the treatment of tuberculosis (TB). Which of the following instructions should the nurse include in the teaching?
- A. Take the medication on an empty stomach.
- B. Discontinue the medication if your saliva turns orange.
- C. Return for another TB skin test in 3 months.
- D. You will need to take this medication for 1 week.
Correct Answer: A
Rationale: The correct answer is A: Take the medication on an empty stomach. Rifampin is best absorbed when taken on an empty stomach, usually 1 hour before or 2 hours after meals. This maximizes its effectiveness in treating TB. Choice B is incorrect because discoloration of body fluids (including saliva) is a known side effect of rifampin and does not indicate the need to discontinue the medication. Choice C is incorrect because the client should not return for another TB skin test in 3 months unless specifically instructed by the healthcare provider. Choice D is incorrect because treatment for TB usually lasts for several months, not just 1 week.
A nurse is reviewing a list of current medications for a client who is starting therapy with furosemide. Which of the following medications should the nurse identify as being contraindicated?
- A. Levothyroxine
- B. Lithium carbonate
- C. Albuterol
- D. Cetirizine
Correct Answer: B
Rationale: The correct answer is B: Lithium carbonate. Furosemide can cause sodium depletion, leading to increased lithium levels and potential lithium toxicity. Levothyroxine (A) is not contraindicated with furosemide. Albuterol (C) may increase the risk of hypokalemia when used with furosemide but is not a contraindication. Cetirizine (D) does not have significant interactions with furosemide.
A nurse in an influenza clinic is collecting data from four clients. Which of the following clients should the nurse identify as having a contraindication for receiving the live attenuated form of the influenza vaccine?
- A. An adolescent who received a new tattoo last week
- B. A client is at 27 weeks of gestation
- C. A client who is about to travel to a different country
- D. A school-age child who has rhinitis
Correct Answer: B
Rationale: The correct answer is B - A client at 27 weeks of gestation. Pregnant individuals are contraindicated to receive live attenuated influenza vaccine due to theoretical risk to the fetus. This is because live vaccines are not recommended during pregnancy. Choice A is incorrect as a recent tattoo does not contraindicate the vaccine. Choice C is incorrect as travel plans do not affect the decision to administer the vaccine. Choice D is incorrect as rhinitis is not a contraindication.