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A nurse is preparing to administer heparin subcutaneously to a client who has deep vein thrombosis. Which of the following actions should the nurse take?
- A. Insert the needle at a 90-degree angle.
- B. Massage the injection site after administering the heparin.
- C. Prepare for a blood test prior to injecting the heparin.
- D. Select a 22-gauge needle for heparin administration.
Correct Answer: A
Rationale: Correct Answer: A: Insert the needle at a 90-degree angle.
Rationale: When administering heparin subcutaneously, the nurse should insert the needle at a 90-degree angle to ensure proper delivery of the medication into the subcutaneous tissue. This angle allows for optimal absorption and effectiveness of the medication. Additionally, it minimizes the risk of injecting the medication into muscle tissue, which could lead to complications.
Summary of other choices:
B: Massaging the injection site after administering heparin is not recommended as it can cause bruising or discomfort.
C: There is no need to prepare for a blood test prior to injecting heparin subcutaneously.
D: A 22-gauge needle is too large for subcutaneous injection and can cause pain and tissue damage.
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A nurse in a provider's office is collecting data from a client who has hypothyroidism. Which of the following should the nurse expect?
- A. Bradycardia.
- B. Moist skin.
- C. Blurred vision.
- D. Insomnia.
Correct Answer: A
Rationale: The correct answer is A: Bradycardia. In hypothyroidism, there is a decrease in thyroid hormone production, leading to a slowed metabolism. This results in bradycardia, or a slow heart rate, as the thyroid hormone plays a role in regulating heart function. Moist skin (B), blurred vision (C), and insomnia (D) are not typically associated with hypothyroidism; instead, dry skin, vision changes, and fatigue are more common symptoms.
A nurse is reinforcing teaching with a client who has a new prescription for nebulizer treatments. Which of the following client statements indicates to the nurse a need for further teaching?
- A. I should wash the mouthpiece with warm soapy water each day.
- B. I'll store my nebulizer at room temperature.
- C. I won't seal my lips around the mouthpiece and take slow, deep breaths.
- D. I'll keep medication in my nebulizer at all times.
Correct Answer: C
Rationale: The correct answer is C because not sealing the lips around the mouthpiece and taking slow, deep breaths can lead to improper inhalation of the medication. This can result in reduced effectiveness of the nebulizer treatment. Choice A is correct as cleaning the mouthpiece daily prevents bacterial growth. Choice B is correct as storing the nebulizer at room temperature maintains medication efficacy. Choice D is incorrect as keeping medication in the nebulizer at all times can lead to contamination and reduced effectiveness.
A nurse Rover medical-surgical unit is caring for a client who asks to review his medical record. Which of the following responses should the nurse make?
- A. You will have to submit a written request for access to your record.
- B. We will provide you a copy of your records when we are preparing you for discharge.
- C. Sorry, but you do not have the time to read your chart.
- D. I can set up a time for you to meet with your provider to go over your medical record.
Correct Answer: D
Rationale: The correct answer is D. The nurse should set up a time for the client to meet with their provider to go over their medical record. This response respects the client's right to access their medical information in a timely and organized manner, ensuring they can fully understand their health status and treatment plan. Option A delays the process with unnecessary paperwork. Option B limits access to records only at discharge. Option C dismisses the client's request. Options E, F, and G are irrelevant.
The physician orders vancomycin hydrochloride 2 g/day by mouth in 4 divided doses. The pharmacy fills the client's prescription with 500 mg vancomycin hydrochloride capsules. The nurse should instruct the client to take______capsule(s) per dose.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: To calculate how many capsules to take per dose, divide the total daily dose (2 g) by the strength of each capsule (500 mg).
1. Convert 2 g to mg: 2 g = 2000 mg
2. Divide 2000 mg by 500 mg per capsule: 2000 mg / 500 mg = 4 capsules per day
3. Since the prescription is to be taken in 4 divided doses, the client should take 1 capsule per dose.
Summary:
B: Incorrect - Not the correct calculation based on the dose and capsule strength.
C: Incorrect - Not the correct calculation based on the dose and capsule strength.
D: Incorrect - Not the correct calculation based on the dose and capsule strength.
E: Incorrect - Not the correct calculation based on the dose and capsule strength.
F: Incorrect - Not the correct calculation based on the dose and capsule strength.
G: Incorrect - Not the correct calculation
A nurse suspects that another nurse on the unit is removing a small amount of morphine from the syringe before administering the medication to the client. Which of the following actions should the nurse take?
- A. Inform the charge nurse about her suspicion.
- B. Report the incident to the hospital security department.
- C. Ask the assistant personnel (AP) to observe the other nurse's actions.
- D. Approach the other nurse to discuss her suspicion.
Correct Answer: A
Rationale: The correct answer is A: Inform the charge nurse about her suspicion. This is the appropriate action as it involves escalating the concern to the appropriate authority, who can investigate the issue further. The charge nurse has the authority to address the situation and take necessary actions to ensure patient safety. Reporting to the security department (B) may not be necessary at this initial stage. Asking the assistant personnel (C) may not be effective in addressing the issue discreetly. Approaching the other nurse directly (D) may lead to confrontation and compromise the investigation process.