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A nurse is preparing to administer an insulin injection for a client. Which of the following actions should the nurse take?
- A. Administer the insulin using a tuberculin syringe at a 15° angle.
- B. Rapidly inject the insulin using a 20-gauge 1-inch needle.
- C. Insert the needle into the right thigh at a 90° angle.
- D. Slowly inject the insulin using the Z-track method.
Correct Answer: C
Rationale: The correct answer is C: Insert the needle into the right thigh at a 90° angle. When administering insulin, the thigh is a recommended site for injection due to its larger muscle mass, which helps with consistent absorption. Inserting the needle at a 90° angle ensures proper depth for subcutaneous injection. This method also minimizes the risk of injecting into a blood vessel or reaching deeper tissues. Using the right thigh allows for rotation of injection sites, preventing lipodystrophy. Administering at a 90° angle promotes optimal absorption and minimizes discomfort for the client.
Choice A is incorrect because a tuberculin syringe is not typically used for insulin administration, and a 15° angle is too shallow for a subcutaneous injection. Choice B is incorrect as a 20-gauge needle is too large for insulin injections, which are typically administered with smaller gauge needles. Choice D is incorrect as the Z-track method is not used for insulin injections, and a slow
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A nurse is collecting data from a client who has been taking carbamazepine. Which of the following is an adverse effect of carbamazepine and should be reported to the provider?
- A. Sore throat
- B. Increased salivation
- C. Urge incontinence
- D. Gingivitis
Correct Answer: A
Rationale: The correct answer is A: Sore throat. Carbamazepine can cause agranulocytosis, a serious condition characterized by a decrease in white blood cells, leading to symptoms like sore throat. This is a potentially life-threatening adverse effect that should be reported to the provider immediately. Increased salivation (choice B), urge incontinence (choice C), and gingivitis (choice D) are not common adverse effects of carbamazepine and do not require immediate reporting.
A nurse is reinforcing teaching with a client who has a prescription for sildenafil to treat erectile dysfunction. Which of the following statements by the client indicates an understanding of the teaching?
- A. This medication will protect me from sexually transmitted diseases.
- B. I will avoid eating fatty foods, while I take this medication.
- C. I should take this medication twice each day.
- D. I can expect to have constipation while I take this medication.
Correct Answer: B
Rationale: The correct answer is B. Eating fatty foods can delay the absorption of sildenafil, so avoiding them can help the medication work effectively. Choice A is incorrect because sildenafil does not protect against STDs. Choice C is incorrect as sildenafil is usually taken as needed, not twice daily. Choice D is incorrect as constipation is not a common side effect of sildenafil.
A nurse is monitoring a client who is receiving a transfusion of packed RBCs. The nurse should identify which of the following findings as an indication of a febrile nonhemolytic reaction?
- A. Dyspnea
- B. Urticaria
- C. Chills
- D. Vomiting
Correct Answer: C
Rationale: The correct answer is C: Chills. A febrile nonhemolytic reaction during a blood transfusion is characterized by the sudden onset of chills and fever, usually within the first 15 minutes to 2 hours of the transfusion. This reaction is caused by the recipient's antibodies reacting to donor leukocytes. Dyspnea (A), urticaria (B), and vomiting (D) are more indicative of other transfusion reactions such as an allergic reaction, hemolytic reaction, or bacterial contamination, respectively.
A nurse is reinforcing teaching with a client who has a new prescription for sustained-release verapamil. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will crush the tablet to make it easier to swallow.
- B. I will increase my daily intake of fiber and fluid.
- C. I will follow up with monthly laboratory tests to check for anemia.
- D. I will sit upright for 30 minutes after taking the medication.
Correct Answer: B
Rationale: The correct answer is B: I will increase my daily intake of fiber and fluid. This response indicates understanding because sustained-release verapamil can cause constipation as a side effect. Increasing fiber and fluid intake can help prevent constipation and promote proper bowel function. Crushing sustained-release tablets can alter the drug's intended release mechanism, leading to potential overdose or underdose. Following up with monthly laboratory tests for anemia is not directly related to verapamil therapy. Sitting upright after taking the medication is more relevant for bisphosphonates to prevent esophageal irritation.
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.