Nokea
A nurse is preparing to administer heparin subcutaneously to a client. Which of the following actions should the nurse plan to take?
- A. Administer the medication outside the 5 cm (2 in) radius of the umbilicus.
- B. Aspirate for blood return before injecting.
- C. Rub vigorously after the injection to promote absorption.
- D. Place a pressure dressing on the injection site to prevent bleeding.
Correct Answer: A
Rationale: The correct answer is A: Administer the medication outside the 5 cm (2 in) radius of the umbilicus. This is because injecting heparin near the umbilicus can lead to bruising or hematoma formation. Subcutaneous injections are generally given in the fatty tissue of the abdomen, but it is important to avoid the area around the umbilicus to prevent discomfort and complications. Aspiration for blood return (B) is not necessary for subcutaneous injections as they are not typically administered into a blood vessel. Rubbing vigorously after the injection (C) is not recommended as it can cause tissue damage. Placing a pressure dressing on the injection site (D) is also unnecessary for subcutaneous injections.
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Which of the following findings should the nurse report to the provider as an adverse effect of gentamicin?
- A. Constipation
- B. Tinnitus
- C. Hypoglycemia
- D. Joint pain
Correct Answer: B
Rationale: The correct answer is B: Tinnitus. Gentamicin is an aminoglycoside antibiotic known to cause ototoxicity, including tinnitus. Tinnitus is characterized by ringing or buzzing in the ears and can be an early sign of auditory nerve damage. This adverse effect should be reported to the provider promptly to prevent further hearing loss.
A: Constipation is not a typical adverse effect of gentamicin.
C: Hypoglycemia is not a known adverse effect of gentamicin.
D: Joint pain is not commonly associated with gentamicin use.
Which of the following adverse effects should the nurse include in the teaching for a client who is to begin taking tamoxifen for the treatment of breast cancer?
- A. Urinary retention
- B. Constipation
- C. Bradycardia
- D. Hot flashes
Correct Answer: D
Rationale: The correct answer is D: Hot flashes. Tamoxifen is known to cause hot flashes as a common side effect due to its estrogen-blocking properties. This is important to include in teaching as it can affect the client's quality of life. Urinary retention (A), constipation (B), and bradycardia (C) are not commonly associated with tamoxifen use. Hot flashes are a well-documented side effect, making it the most appropriate choice for client education.
Which of the following over-the-counter medications should the nurse identify that the client should discontinue when starting lithium?
- A. Aspirin
- B. Ibuprofen
- C. Famotidine
- D. Bisacodyl
Correct Answer: B
Rationale: The correct answer is B: Ibuprofen. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can increase lithium levels and lead to toxicity. NSAIDs compete with lithium for renal excretion, resulting in higher lithium levels. Aspirin (choice A) is not typically contraindicated with lithium. Famotidine (choice C) and Bisacodyl (choice D) do not have significant interactions with lithium.
Which of the following statements should the nurse include in the teaching about the new medication? Select the 2 statements the nurse should include in the teaching.
- A. You should take medication with dairy products
- B. This medication may cause constipation.
- C. It is common to experience headache or blurred vision while taking this medication.
- D. You should avoid the sun while taking this medication.
Correct Answer: B, D
Rationale: The correct answers are B and D. Statement B is important as it informs the patient about a potential side effect (constipation) of the medication, promoting awareness and preparedness. Statement D is crucial as some medications can increase sensitivity to sunlight, leading to adverse reactions like sunburn. Choices A, C, and the remaining options are incorrect as taking medication with dairy products can interfere with absorption, experiencing headache or blurred vision is not common for all medications, and not all medications require sun avoidance.
Complete the following sentence by using the lists of options. Upon analyzing the assessment findings, the nurse identifies that the client is at risk for _______ due to _______.
- A. concurrent medication use
- B. recent illness
- C. activity level
Correct Answer: A
Rationale: The correct answer is A: concurrent medication use. This is because identifying a client at risk for a condition due to concurrent medication use is crucial in nursing assessment. Medications can interact with each other, leading to adverse effects or reduced efficacy. Recent illness (B) and activity level (C) are important factors but do not directly relate to the risk due to medication use. The other choices (D, E, F, G) are irrelevant and do not address the potential risks associated with medication interactions. Thus, A is the most appropriate choice for identifying a client's risk based on assessment findings related to medication use.