Nokea
A nurse is preparing to administer medications to a client. Which of the following client identifiers should the nurse use to verify that the correct client is receiving the medication? (Select all that apply.)
- A. Date of birth
- B. Facility identification number
- C. Name
- D. Physical location
- E. Room number
Correct Answer: A, B, C
Rationale: The correct identifiers for verifying the client are date of birth, facility identification number, and name. Date of birth ensures the client's age and helps avoid mix-ups with clients of the same name. Facility identification number uniquely identifies the client within the facility. Name is crucial for confirming the client's identity verbally. Physical location and room number are not reliable identifiers as clients may move within the facility. Overall, using a combination of unique identifiers helps prevent medication errors and ensures the correct client receives the right medication.
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A nurse is caring for a client who has prescriptions for spironolactone and lisinopril. The nurse should monitor for which of the following adverse effects?
- A. Hyperkalemia
- B. Hypoglycemia
- C. Hypokalemia
- D. Hyperglycemia
Correct Answer: A
Rationale: The correct answer is A: Hyperkalemia. Spironolactone is a potassium-sparing diuretic, which can lead to elevated potassium levels (hyperkalemia). Lisinopril is an ACE inhibitor that may also contribute to increased potassium levels. Monitoring for hyperkalemia is essential due to the risk of serious cardiac arrhythmias. Hypoglycemia (choice B) and hyperglycemia (choice D) are not typically associated with these medications. Hypokalemia (choice C) is the opposite of what is expected with spironolactone.
A nurse is preparing to administer an IM injection to a client who has gonorrhea. Which of the following actions should the nurse take?
- A. Inject the medication at least 5 cm (2 in) from the umbilicus.
- B. Administer the medication with a 27-gauge /0.5 inch needle.
- C. Use the Z-track technique to administer the medication.
- D. Give the medication without aspirating prior to injection.
Correct Answer: C
Rationale: The correct answer is C: Use the Z-track technique to administer the medication. The Z-track technique involves pulling the skin laterally before injecting the medication to prevent leakage and irritation. This is crucial when administering IM injections to prevent the medication from leaking into the subcutaneous tissue. Option A is incorrect because the injection site for IM injections should be at least 2.5 cm (1 inch) away from the umbilicus. Option B is incorrect because a larger needle gauge (e.g., 22-25 gauge) is typically used for IM injections to reduce discomfort and prevent medication leakage. Option D is incorrect because aspirating prior to injection is not necessary for IM injections and may cause tissue damage.
A nurse is caring for a client who has a new diagnosis of schizophrenia. Which of the following medications should the nurse expect to administer?
- A. Levodopa
- B. Baclofen
- C. Fenofibrate
- D. Risperidone
Correct Answer: D
Rationale: The correct answer is D: Risperidone. Risperidone is an antipsychotic medication commonly used to treat schizophrenia by helping to manage symptoms such as hallucinations and delusions. Levodopa (A) is used for Parkinson's disease, Baclofen (B) is a muscle relaxant, and Fenofibrate (C) is used to lower cholesterol. Administering any of these medications to a client with schizophrenia would not address their symptoms effectively.
A nurse is preparing to administer an influenza immunization IM to an infant. Which of the following actions should the nurse include in the plan of care?
- A. Use a ½-Inch needle.
- B. Use a 22-gauge needle.
- C. Use the flushing technique.
- D. Use the deltoid muscle for the injection site.
Correct Answer: A
Rationale: The correct answer is A: Use a ½-Inch needle. For infants, a ½-inch needle is recommended for intramuscular (IM) injections to ensure proper administration of the vaccine into the muscle. Using a shorter needle decreases the risk of reaching the bone or causing tissue damage.
B: Using a 22-gauge needle is not specific to infants and may not be the most appropriate size for their smaller muscles.
C: The flushing technique is not relevant to the administration of the vaccine.
D: The deltoid muscle is not typically used as the injection site for infants; the vastus lateralis muscle is more commonly used due to its larger muscle mass and ease of access.
In summary, using a ½-inch needle is the correct choice for an infant receiving an IM influenza immunization to ensure safe and effective administration.
A nurse is reinforcing teaching with a client who has a prescription for alendronate. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will drink orange juice when I take this medication.
- B. I will remain seated for 30 minutes after I take my medication.
- C. I will take this medication right before I go to bed.
- D. I can take this medication just once a month.
Correct Answer: C
Rationale: The correct answer is C: "I will take this medication right before I go to bed." Alendronate should be taken on an empty stomach, in the morning, at least 30 minutes before the first food, drink, or medication of the day. Taking it before bed ensures the client has an empty stomach. Choice A is incorrect because orange juice can interfere with alendronate absorption. Choice B is incorrect as sitting upright for 30 minutes after taking the medication is the recommended action. Choice D is incorrect as alendronate is typically taken weekly, not monthly.