Nokea
A nurse is preparing to administer erythromycin PO to a client who has an infection. The nurse checks the client's medical record and notes that the client has a severe allergy to penicillin. Which of the following actions should the nurse take?
- A. Request a different medication from the provider.
- B. Premedicate the client with diphenhydramine.
- C. Administer the medication to the client.
- D. Request a different route of administration from the provider.
Correct Answer: C
Rationale: Rationale: The correct action is to administer the medication to the client (Choice C) because erythromycin is not related to penicillin and is safe to use in clients with a penicillin allergy. Requesting a different medication (Choice A) may not be necessary as erythromycin is a suitable alternative. Premedicating with diphenhydramine (Choice B) is not indicated for a penicillin allergy. Requesting a different route of administration (Choice D) is unnecessary since the oral route is appropriate for erythromycin.
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A nurse is reinforcing discharge teaching with a client who has a new diagnosis of type 2 diabetes mellitus and a prescription for exenatide. Which of the following instructions should the nurse include in the teaching?
- A. Contact the provider if you experience unexplained muscle pain.
- B. Take the medication at bedtime.
- C. Discard excess medication after 60 days.
- D. Inject the medication into the subcutaneous tissue of your abdomen.
Correct Answer: D
Rationale: The correct answer is D: Inject the medication into the subcutaneous tissue of your abdomen. Exenatide is a medication that is administered through subcutaneous injection, typically into the abdomen. This is the correct route of administration to ensure proper absorption and effectiveness of the medication. Option A is incorrect as it is not directly related to the administration of exenatide. Option B is incorrect because exenatide is usually taken before meals, not at bedtime. Option C is incorrect as the disposal timeline for exenatide is typically shorter than 60 days.
Vital Signs
Nurses' Notes
History and Physical
Initial visit:
Temperature 36.5° C (97.7° F)
Heart rate 68/min
Blood pressure 116/70 mm Hg
Respiratory rate 16/min
SpO2 98% on room air
Follow-up visit 2 weeks later:
Temperature 36.7° C (98.1° F)
Heart rate 86/min
Blood pressure 130/80 mm Hg
Respiratory rate 18/min.
SpO2 99% on room air
Select the 6 statements the nurse should include when reinforcing teaching to the client about the newly prescribed medication.
- A. This medication should start to alleviate the headache within 1 hour.
- B. You might experience a feeling of pressure in your chest after taking this medication.
- C. Do not take more than 200 milligrams of this medication within 24 hours.
- D. You can take a second dose of this medication at least 2 hours after the initial dose if the headache persists.
- E. You should discontinue this medication if pregnancy is planned or suspected.
- F. This medication can cause you to feel tired.
- G. You might experience a rash on your skin while taking this medication.
Correct Answer: A,B,C,D,E,F
Rationale: The correct answer includes statements covering various important aspects of the medication. A: Ensures client knows when to expect relief. B: Alerts to potential side effect. C: Provides clear dosing instructions. D: Instructs on when and how to take a second dose. E: Important for safety during pregnancy. F: Warns about potential side effect. Explanations for incorrect choices: G: Not as crucial as the other statements.
A nurse is preparing to administer 0800 medications to a client. The medication administration record (MAR) states 'phenobarbital' and the medication the pharmacy supplied is pentobarbital. Which of the following actions should the nurse take?
- A. Check the client's MAR to see what the client received the day before
- B. Ask the client what medication she took yesterday.
- C. Ask the client if she has any allergies.
- D. Check the prescription in the client's medical record.
Correct Answer: D
Rationale: The correct answer is D: Check the prescription in the client's medical record. This is the appropriate action for the nurse to take because it ensures that the medication being administered matches the prescription ordered by the healthcare provider. By verifying the prescription in the client's medical record, the nurse can confirm if pentobarbital is indeed the correct medication prescribed for the client. Checking the MAR alone may not provide the necessary information about the prescribed medication. Asking the client about previous medications or allergies (choices A, B, C) may not be reliable sources of information regarding the specific prescription. Therefore, option D is the most appropriate and logical course of action in this situation.
A nurse is reinforcing teaching with a client who has a new prescription for prednisone to treat rheumatoid arthritis. Which of the following statements should indicate to the nurse that the client understands the teaching?
- A. I should watch for weight loss.
- B. I should increase the sodium in my diet.
- C. I will take this medication on an empty stomach.
- D. I will report a sore throat to my provider.
Correct Answer: D
Rationale: The correct answer is D: "I will report a sore throat to my provider." This is the correct answer because prednisone can suppress the immune system, increasing the risk of infections like thrush or sore throat. Reporting these symptoms promptly is crucial to prevent complications.
Choice A is incorrect because prednisone can actually cause weight gain. Choice B is incorrect because prednisone can lead to fluid retention, so increasing sodium intake is not recommended. Choice C is incorrect because prednisone should be taken with food to reduce stomach upset.
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.