Nokea
A nurse is preparing to administer the initial dose of penicillin G IM to a client. The nurse should monitor for which of the following as an indication of an allergic reaction following the injection?
- A. Urticaria
- B. Bradycardia
- C. Pallor
- D. Dyspepsia
Correct Answer: A
Rationale: The correct answer is A: Urticaria. Urticaria, or hives, is a classic sign of an allergic reaction. It presents as raised, red, itchy welts on the skin. This occurs due to histamine release in response to the allergen (penicillin in this case). Monitoring for urticaria is crucial as it indicates a potentially serious allergic reaction that may progress to anaphylaxis. Bradycardia (B), Pallor (C), and Dyspepsia (D) are not typically associated with allergic reactions to penicillin. Bradycardia is a slow heart rate, pallor is paleness of the skin, and dyspepsia is indigestion. These symptoms are more likely related to other conditions or side effects rather than an allergic reaction.
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A nurse inadvertently administers 160 mg of valsartan PO to a client who was scheduled to receive 80 mg. Which of the following actions is the priority for the nurse to take?
- A. Evaluate the client for orthostatic hypotension.
- B. Monitor the client's urine output.
- C. Obtain the client's laboratory results.
- D. Check the client for nasal congestion.
Correct Answer: A
Rationale: The correct answer is A: Evaluate the client for orthostatic hypotension. This is the priority because an overdose of valsartan, a medication used to treat hypertension, can lead to a sudden drop in blood pressure. Orthostatic hypotension is a potential complication that can result from this overdose, and it requires immediate assessment and intervention to prevent further complications such as falls or decreased perfusion to vital organs. Monitoring urine output (B) is important for some medications but is not the priority in this case. Obtaining laboratory results (C) may be necessary in the long term but is not urgent in this situation. Checking for nasal congestion (D) is not relevant to the issue at hand.
A nurse is administering naloxone to a client who has developed an adverse reaction to morphine. The nurse should identify which of the following findings as a therapeutic effect of naloxone?
- A. Decreased nausea
- B. Increased pain relief
- C. Decreased blood pressure
- D. Increased respiratory rate
Correct Answer: D
Rationale: The correct answer is D: Increased respiratory rate. Naloxone is an opioid antagonist that works by blocking the effects of opioids, such as morphine. By administering naloxone to the client experiencing an adverse reaction to morphine, the nurse can reverse the respiratory depression caused by the morphine. This reversal leads to an increase in the client's respiratory rate, which is a therapeutic effect of naloxone in this situation.
Incorrect choices:
A: Decreased nausea - Naloxone does not directly address nausea.
B: Increased pain relief - Naloxone does not provide pain relief but reverses the effects of opioids.
C: Decreased blood pressure - Naloxone may lead to an increase in blood pressure due to its effects on reversing opioid-induced respiratory depression.
A nurse Is evaluating the laboratory results of four clents. The nurse should report which of the following laboratory results should the nurse report to the provider?
- A. A client who has a prescription for heparin and an aPTT of 90 seconds (30-40 seconds).
- B. A client who has a prescription for heparin and an aPTT of 65 seconds (30-40 seconds).
- C. A client who has a prescription for warfarin and an INR of 3.0 (0.8 to 1.1).
- D. A client who has a prescription for warfarin and an INR of 2.0 (0.8 to 1.1).
Correct Answer: A
Rationale: Correct Answer: A
Rationale: A client with a prescription for heparin and an aPTT of 90 seconds indicates that the client's blood is taking too long to clot, which puts the client at risk for bleeding. The aPTT range for a client on heparin therapy is 30-40 seconds, so a result of 90 seconds is significantly elevated and requires immediate attention to prevent bleeding complications.
Summary of other choices:
B: A client with a prescription for heparin and an aPTT of 65 seconds falls within the normal range of 30-40 seconds, so this result does not require immediate reporting.
C: A client with a prescription for warfarin and an INR of 3.0 is within the therapeutic range (2-3) for warfarin therapy, so this result does not require immediate reporting.
D: A client with a prescription for warfarin and an INR of 2.0 is also
A nurse is preparing to administer subcutaneous heparin to a client. Which of the following should the nurse take?
- A. Massage the site after administering the medication
- B. Use a 21-gauge needle for the injection
- C. Aspirate before injecting the medication
- D. Insert the needle at least 5 cm (2 in) from the umbilicus
Correct Answer: D
Rationale: The correct answer is D: Insert the needle at least 5 cm (2 in) from the umbilicus. This is crucial to prevent any potential harm to the abdominal organs located around the umbilicus. Inserting the needle too close could lead to injury or bleeding. Massaging the site after administering (A) is not recommended as it can cause bruising or discomfort. Using a 21-gauge needle (B) is not specified for subcutaneous heparin injections. Aspirating before injecting (C) is not necessary for subcutaneous injections, as the risk of hitting a blood vessel is low.
A nurse is assessing for allergies with a client who is scheduled to receive the influenza vaccine. Which of the following allergies should the nurse report to the provider as a possible contraindication to receiving the vaccine?
- A. Eggs
- B. Shellfish
- C. Peanuts
- D. Milk
Correct Answer: A
Rationale: The correct answer is A: Eggs. Influenza vaccines are typically produced using eggs, so individuals with egg allergies may have an allergic reaction to the vaccine. Reporting this allergy to the provider is crucial to avoid potential adverse reactions. Shellfish, peanuts, and milk allergies are not contraindications for receiving the influenza vaccine. Summary: Eggs are the correct answer due to the vaccine production method; shellfish, peanuts, and milk allergies are not relevant in this context.