Nokea
A nurse is preparing to administer enoxaparin to a client. Which of the following actions should the nurse take?
- A. Apply firm pressure to the injection site following administration
- B. Administer the medication into the client's muscle
- C. Expel the air bubble from the syringe prior to injection
- D. Insert the syringe needle halfway into the client's skin
Correct Answer: A
Rationale: Correct Answer: A: Apply firm pressure to the injection site following administration.
Rationale: Applying firm pressure to the injection site following administration of enoxaparin helps minimize the risk of bleeding, as enoxaparin is an anticoagulant medication. This pressure promotes clot formation and reduces the likelihood of bruising or hematoma formation at the injection site.
Summary of other choices:
B: Administer the medication into the client's muscle - Incorrect. Enoxaparin is a subcutaneous medication, not meant for intramuscular administration.
C: Expel the air bubble from the syringe prior to injection - Good practice but not directly related to the administration of enoxaparin.
D: Insert the syringe needle halfway into the client's skin - Incorrect. The needle should be fully inserted for proper subcutaneous injection.
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A nurse is caring for a client who has a prescription for total parenteral nutrition (TPN). Which of the following routes of administration should the nurse use?
- A. Subcutaneous
- B. Intravenous
- C. Central venous access device
- D. Midline catheter
Correct Answer: C
Rationale: The correct answer is C: Central venous access device. TPN is a highly concentrated solution that provides all the nutrients a person needs intravenously. A central venous access device allows for the infusion of TPN into a large central vein, such as the superior vena cava, ensuring immediate access to the bloodstream for rapid absorption. Using other routes like subcutaneous (A), intravenous (B), or midline catheter (D) may not be suitable due to the high osmolarity of TPN, which can cause irritation and damage to smaller veins. Therefore, a central venous access device is the most appropriate and safe route for administering TPN.
A nurse is providing teaching to a client who has a new prescription for clozapine. Which of the following statements should the nurse include in the teaching?
- A. Diarrhea is a common adverse effect of this medication.
- B. Ringing in the ears is an expected adverse effect of this medication.
- C. Notify your provider if you develop a fever while taking this medication.
- D. You might experience weight loss while taking this medication.
Correct Answer: C
Rationale: The correct answer is C: Notify your provider if you develop a fever while taking this medication. This is important because clozapine can cause a serious condition called agranulocytosis, which can lead to a fever. The nurse should emphasize the significance of monitoring for fever and promptly notifying the healthcare provider. Choice A is incorrect because diarrhea is not a common adverse effect of clozapine. Choice B is incorrect as ringing in the ears is not an expected adverse effect. Choice D is incorrect because weight gain, not weight loss, is a common side effect of clozapine.
A nurse is caring for a client who has a prescription for amoxicillin. Which of the following findings indicates the client is experiencing an allergic reaction?
- A. Nausea
- B. Cardiac dysrhythmia
- C. Laryngeal edema
- D. Insomnia
Correct Answer: C
Rationale: The correct answer is C: Laryngeal edema. Laryngeal edema is a severe allergic reaction symptom that can lead to airway obstruction and respiratory distress. This is a life-threatening condition that requires immediate intervention. Nausea (A) and insomnia (D) are common side effects of amoxicillin but not indicative of an allergic reaction. Cardiac dysrhythmia (B) is not a typical allergic reaction symptom to amoxicillin.
A home health nurse is visiting a client who has heart failure and a prescription for furosemide. The nurse identifies that the client has gained 2.5 kg (5 lb.) since the last visit 2 days ago. Which of the following actions should the nurse take first?
- A. Encourage the client to dangle the legs while sitting in a chair
- B. Teach the client about foods low in sodium
- C. Determine medication adherence by the client
- D. Notify the provider of the client's weight gain
Correct Answer: D
Rationale: The correct answer is D: Notify the provider of the client's weight gain. This is the first action the nurse should take because sudden weight gain in a client with heart failure could indicate fluid retention, which may worsen the client's condition. By notifying the provider, the nurse can ensure timely intervention to adjust the medication or treatment plan. Encouraging leg dangling (A) may help with circulation but does not address the immediate concern of weight gain. Teaching about low-sodium foods (B) is important for long-term management but not the priority at this moment. Determining medication adherence (C) is important but should come after addressing the immediate weight gain issue.
A nurse is teaching a newly licensed nurse about medication reconciliation. The nurse should instruct the newly licensed nurse to perform medication reconciliation for which of the following?
- A. A client who has a referral for social services
- B. A client who is transdermal to radiology
- C. A client who is transferal to a stepdown unit
- D. A client who has a consultation for physical therapy
Correct Answer: C
Rationale: The correct answer is C: A client who is transferal to a stepdown unit. Medication reconciliation is crucial during transitions of care to ensure accuracy and safety. When a client is transferred to a stepdown unit, their care level changes, necessitating a review of medications to prevent errors. Choice A is not directly related to medication reconciliation. Choice B involves a procedure, not a care transition requiring medication review. Choice D pertains to therapy but does not involve a care transition.