Nokea
A nurse is preparing to administer acetaminophen 650 mg rectally. Which of the following actions should the nurse take?
- A. Insert the suppository 5 cm (2 in) into the client's rectum.
- B. Lubricate the flat end of the suppository prior to administration.
- C. Have the client lie on his left side for 5 min after insertion.
- D. Hold the suppository for 1 min to warm it prior to insertion.
Correct Answer: C
Rationale: The correct answer is C: Have the client lie on his left side for 5 min after insertion. This position promotes optimal absorption of the medication. When the client lies on the left side, gravity helps keep the suppository in place and allows it to dissolve and be absorbed more effectively through the rectal mucosa. This position also helps prevent the suppository from being expelled prematurely.
Choice A is incorrect because inserting the suppository 5 cm (2 in) is not necessary for proper administration. Choice B is incorrect as lubricating the suppository is not essential for rectal administration. Choice D is incorrect because warming the suppository is not required and may not be safe. Choices E, F, and G are not provided, so they are not applicable in this scenario.
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A nurse is preparing to administer regular insulin 4 units and NPH insulin 10 units subcutaneously to a client who has type 1 diabetes mellitus. Which of the following actions should the nurse take first?
- A. Inject 10 units of air into the NPH insulin vial.
- B. Draw up 10 units from the NPH insulin vial.
- C. Inject 4 units of air into the regular insulin vial.
- D. Draw up 4 units from the regular insulin vial.
Correct Answer: C
Rationale: The correct answer is C: Inject 4 units of air into the regular insulin vial. This action is done to prevent negative pressure in the vial, making it easier to withdraw the correct dose of insulin. By injecting air first, the nurse ensures that the exact amount of insulin can be withdrawn accurately without causing any damage to the vial or affecting the dose.
Choice A is incorrect as injecting air into the NPH insulin vial is not necessary before drawing up the insulin. Choice B is incorrect as drawing up the NPH insulin before preparing the regular insulin would be out of sequence. Choice D is incorrect as drawing up the regular insulin before injecting air into the vial could lead to difficulty in withdrawing the correct dose.
A nurse is reinforcing teaching with a client who has a prescription for alendronate. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will drink orange juice when I take this medication.
- B. I will remain seated for 30 minutes after I take my medication.
- C. I will take this medication right before I go to bed.
- D. I can take this medication just once a month.
Correct Answer: C
Rationale: The correct answer is C: "I will take this medication right before I go to bed." Alendronate should be taken on an empty stomach, in the morning, at least 30 minutes before the first food, drink, or medication of the day. Taking it before bed ensures the client has an empty stomach. Choice A is incorrect because orange juice can interfere with alendronate absorption. Choice B is incorrect as sitting upright for 30 minutes after taking the medication is the recommended action. Choice D is incorrect as alendronate is typically taken weekly, not monthly.
A nurse is caring for a client who has a new prescription for valproic acid. The nurse should review which of the following baseline laboratory values prior to administering the medication?
- A. Arterial blood gases
- B. Liver function tests
- C. Troponin levels
- D. Blood glucose levels
Correct Answer: B
Rationale: The correct answer is B: Liver function tests. Valproic acid is known to potentially cause hepatotoxicity, so it is essential to assess baseline liver function tests before administering the medication. Monitoring liver function tests can help identify any pre-existing liver conditions and prevent further liver damage. Arterial blood gases (A) are not directly related to valproic acid administration. Troponin levels (C) are used to assess heart muscle damage, which is not a concern with valproic acid. Blood glucose levels (D) are not specifically relevant to valproic acid therapy.
A nurse is collecting data from a client who is taking high doses of aspirin to treat rheumatoid arthritis. Which of the following findings indicates that the client has salicylism?
- A. Tinnitus
- B. Nuchal rigidity
- C. Pharyngitis
- D. Pruritus
Correct Answer: A
Rationale: The correct answer is A: Tinnitus. Salicylism is a toxic condition caused by high levels of salicylates, such as aspirin, in the body. Tinnitus is a common early sign of salicylism due to its ototoxic effects on the auditory nerve. Nuchal rigidity, pharyngitis, and pruritus are not typically associated with salicylism. Nuchal rigidity is more indicative of meningitis, pharyngitis suggests a throat infection, and pruritus is itching which is not specific to salicylism. Therefore, tinnitus is the most relevant finding in this context.
History and Physical 2 weeks ago: Client is in the office for evaluation of acne vulgaris. Past medical history significant for worsening acne vulgaris, unresponsive to previous treatments. Client has been taking a combined oral contraceptive as directed for the past year. Comedones and cystic lesions on face, chest, and back. Acne scarring present on cheeks bilaterally and upper back. Liver function tests (LFTs), fasting lipid panel, serum human chorionic gonadotropin (hG) ordered today. Plan to follow up In 2 weeks for review of laboratory results and medication initiation.
Select the 2 educational topics the nurse should prioritize when reinforcing education to the client about the prescribed medication.
- A. Need for vitamin A supplementation
- B. Importance of using two forms of birth control
- C. Monitoring for skin dryness and irritation
- D. Manifestations of depression
- E. Correct application of sunscreen
Correct Answer: B, D
Rationale: The correct answers are B and D. The nurse should prioritize educating the client on birth control and manifestations of depression. Birth control is crucial to prevent unintended pregnancies while on medication. Depression monitoring is essential due to potential side effects. Choices A, C, and E are less critical in the context of medication education. Vitamin A supplementation, skin dryness, and sunscreen application are important but not as immediate as birth control and depression monitoring in this case.