Nokea
A nurse is preparing to administer enoxaparin 5,000 units subcutaneous to a client. Which of the following actions should the nurse take?
- A. Insert the needle at a 45° or 90° angle.
- B. Hold the skin taut during administration
- C. Massage the injection site after administrating the enoxaparin.
- D. Use a 4 cm (1.6in) needle
Correct Answer: A
Rationale: The correct answer is A: Insert the needle at a 45° or 90° angle. When administering enoxaparin subcutaneously, the nurse should insert the needle at a 45° or 90° angle to ensure proper delivery into the subcutaneous tissue. Angling the needle helps prevent injecting the medication too deeply or too superficially, ensuring optimal absorption and effectiveness. Holding the skin taut (choice B) is not required for subcutaneous injections. Massaging the injection site (choice C) after administering enoxaparin is not recommended as it can cause irritation or bruising. Using a 4 cm needle (choice D) is not specified for enoxaparin administration and may not be appropriate for all clients.
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A nurse is caring for a client who is receiving heparin therapy. If the client requires a reversal of the effects of heparin, which of the following medications should the nurse expect the provider to prescribe?
- A. Atropine
- B. Vitamin K
- C. Vitamin B12
- D. Protamine
Correct Answer: D
Rationale: The correct answer is D: Protamine. Protamine is the antidote for heparin as it works by forming a complex with heparin, neutralizing its anticoagulant effects. Atropine (A) is used for bradycardia, not for heparin reversal. Vitamin K (B) is used to reverse the effects of warfarin, a different anticoagulant. Vitamin B12 (C) is not used for heparin reversal. Therefore, the correct choice is Protamine (D) for reversing heparin's effects.
A nurse is caring for a client who has ulcerative colitis and is receiving sulfasalazine. Which of the following findings requires immediate intervention?
- A. Anorexia
- B. Arthralgia
- C. Nausea
- D. Wheezing
Correct Answer: D
Rationale: The correct answer is D: Wheezing. Wheezing is a sign of a severe allergic reaction to sulfasalazine, known as Stevens-Johnson syndrome, which is a medical emergency requiring immediate intervention to prevent respiratory distress and potential anaphylaxis. Anorexia, arthralgia, and nausea are common side effects of sulfasalazine but do not indicate an immediate threat to the client's well-being. Wheezing is the most critical finding that needs urgent attention.
A charge nurse is evaluating a newly licensed nurse caring for a client who is using a PCA device. Which of the following actions by the nurse requires intervention by the charge nurse?
- A. The nurse monitors the client for oversedation
- B. The nurse reassures the client that the PCA device will not cause an overdose
- C. The nurse asks the client to demonstrate dose delivery.
- D. The nurse administers a PCA dose for the client.
Correct Answer: D
Rationale: Correct Answer: D. The nurse administering a PCA dose for the client requires intervention. This is because only the client should be allowed to self-administer medication via a PCA device to ensure safety and prevent medication errors. Allowing the nurse to administer the dose goes against the principles of PCA therapy, which empowers the client to manage their pain relief within safe limits.
Choice A: Monitoring the client for oversedation is a standard nursing practice and does not require intervention.
Choice B: Reassuring the client about the PCA device is important for patient education but does not require immediate intervention.
Choice C: Asking the client to demonstrate dose delivery is a proactive approach to ensure the client understands how to use the device correctly and does not require intervention unless the client is unable to demonstrate understanding.
A nurse is caring for a client who has prescriptions for spironolactone and lisinopril. The nurse should monitor for which of the following adverse effects?
- A. Hypoglycemia
- B. Hyperkalemia
- C. Hyperglycemia
- D. Hypokalemia
Correct Answer: B
Rationale: The correct answer is B: Hyperkalemia. Spironolactone is a potassium-sparing diuretic and can lead to an increase in potassium levels (hyperkalemia). Lisinopril, an ACE inhibitor, can also contribute to this effect. Monitoring for hyperkalemia is crucial as it can lead to serious cardiac complications.
A: Hypoglycemia is not typically associated with spironolactone or lisinopril.
C: Hyperglycemia is not a common adverse effect of spironolactone or lisinopril.
D: Hypokalemia is unlikely with spironolactone, as it tends to increase potassium levels.
In summary, monitoring for hyperkalemia is essential when a client is taking spironolactone and lisinopril due to the potential for adverse cardiac events.
A nurse is collecting data from a client before administering a hepatitis B immunization. The nurse should withhold the immunization if the client is allergic to which of the following substances?
- A. Baker's yeast
- B. Nuts
- C. Wheat
- D. Egg yolk
Correct Answer: A
Rationale: The correct answer is A: Baker's yeast. Hepatitis B vaccines are produced using baker's yeast, specifically Saccharomyces cerevisiae. If a client is allergic to baker's yeast, there is a risk of an allergic reaction to the vaccine. Nuts (B), wheat (C), and egg yolk (D) are not ingredients used in the hepatitis B vaccine production, so allergies to these substances would not necessitate withholding the immunization.