Nokea
A nurse is preparing to administer medication to a client who has a new prescription. Which of the following actions should the nurse take first?
- A. Calculate the correct amount of the medication.
- B. Validate the prescription with the available medication.
- C. Document the time of the medication administration.
- D. Identify the client using two means of identification
Correct Answer: D
Rationale: The correct action for the nurse to take first is to identify the client using two means of identification. This is crucial to ensure the right medication is given to the right patient, preventing errors and ensuring patient safety. By verifying the client's identity, the nurse can confirm they are administering the medication to the correct individual. This step helps prevent medication errors and ensures accountability.
Calculating the correct amount of medication (A) is important but should come after verifying the patient's identity. Validating the prescription with available medication (B) is also important but not the first step. Documenting the time of medication administration (C) is essential but should follow patient identification.
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Nurses' Notes
0800:
Client reports frequent cough, wheezing, and tightness of chest. Bilateral breath sounds with scattered inspiratory and expiratory wheezes.
1000:
Reinforced teaching about newly prescribed medications.
Click to highlight the instructions the nurse should reinforce to the client.
- A. Take your albuterol when you are having difficulty breathing.
- B. Hold your breath for 20 seconds when taking your albuterol.
- C. Take the salmeterol 5 minutes before the albuterol when you need both medications.
- D. Take the salmeterol 2 times each day.
- E. Rinse out your mouth after taking the fluticasone.
- F. Take the fluticasone as needed for an asthma attack.
Correct Answer: A,D,E
Rationale: Sure, here is a detailed explanation for each choice:
A: Taking albuterol during difficulty breathing helps relieve symptoms promptly.
D: Salmeterol should be taken twice daily for optimal effectiveness.
E: Rinsing mouth after fluticasone reduces the risk of oral thrush.
Incorrect choices:
B: Holding breath doesn't affect albuterol efficacy.
C: Timing salmeterol before albuterol isn't necessary.
F: Fluticasone is a controller, not a rescue inhaler.
A nurse is caring for a client who has been taking epoetin alfa for 3 months. Which of the following laboratory tests should the nurse monitor to determine the effectiveness of the medication?
- A. Troponin
- B. Thyroxine (T4)
- C. Aspartate aminotransferase (AST)
- D. Hgb
Correct Answer: D
Rationale: The correct answer is D: Hgb (hemoglobin). Epoetin alfa is a medication used to stimulate red blood cell production. Monitoring hemoglobin levels is crucial to assess the effectiveness of the medication in increasing red blood cell count. Hemoglobin reflects the oxygen-carrying capacity of red blood cells, indicating if the medication is addressing the underlying anemia. Troponin (A) is used to assess heart muscle damage, not relevant in this case. Thyroxine (B) reflects thyroid function, not related to epoetin alfa therapy. Aspartate aminotransferase (AST) (C) is a liver enzyme, not relevant for monitoring this medication's efficacy.
A nurse is administering the first dose of ramipril to a client who has hypertension. The client reports feeling dizzy and lightheaded. Which of the following should the nurse administer?
- A. 15 g of carbohydrates
- B. Naloxone
- C. Diphenhydramine
- D. Fluid bolus
Correct Answer: D
Rationale: The correct answer is D: Fluid bolus. The client is experiencing symptoms of hypotension, a common side effect of ramipril. Administering a fluid bolus helps increase blood volume, improving blood pressure and alleviating dizziness and lightheadedness. It is important to address the underlying cause of the symptoms. Choices A, B, and C are not appropriate in this situation as they do not address the hypotension caused by ramipril. Administering carbohydrates (A) is irrelevant, naloxone (B) is used for opioid overdose, and diphenhydramine (C) is an antihistamine and not indicated for hypotension.
A nurse is reinforcing discharge teaching about sublingual nitroglycerin with a client who has angina. Which of the following statements indicates an understanding of the instructions?
- A. I understand that the medication can slow my heart rate.
- B. I am going to take the medication with food.
- C. I will take the medication every 10 minutes until the pain goes away.
- D. I should feel the effects of the medication within 5 minutes.
Correct Answer: D
Rationale: Correct Answer: D
Rationale: Nitroglycerin is a fast-acting medication used to relieve angina symptoms. Choosing option D shows understanding because nitroglycerin should provide relief within 5 minutes if the medication is effective. This rapid onset is crucial in managing acute angina attacks. Taking the medication every 10 minutes (C) could lead to overdose and severe side effects. Slow heart rate (A) is not a common side effect of nitroglycerin. Taking with food (B) may delay absorption and reduce effectiveness.
A nurse is reinforcing teaching with the parents of a 13-month-old child following administration of the measles mumps rubella (MMR) Immunization. Which of the following statements by the nurse is appropriate?
- A. Your child will receive another MMR immunization and the hepatitis B immunization at 3 years of age.
- B. Your child will receive two more MMR immunizations over the next 2 years.
- C. Your child will receive another MMR immunization at 4 to 6 years of age.
- D. Your child will have an MMR titer taken to determine the need for further immunizations.
Correct Answer: C
Rationale: The correct answer is C because at 13 months, the child receives the first dose of MMR vaccine. The second dose is usually given at 4 to 6 years of age to ensure long-term immunity. Option A is incorrect as hepatitis B is not typically given at 3 years of age with MMR. Option B is incorrect because only one more dose of MMR is usually needed. Option D is incorrect because titers are not routinely done for MMR vaccine.