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A nurse is preparing to administer vaccines to an 11-year-old child who is up to date on immunizations. Which of the following vaccines should the nurse plan to administer?
- A. Quadrivalent human papillomavirus
- B. Rotavirus
- C. Pneumococcal conjugate
- D. Hepatitis B
Correct Answer: A
Rationale: The correct answer is A: Quadrivalent human papillomavirus vaccine. At age 11, the child should receive the HPV vaccine as part of routine immunization. HPV vaccination is recommended for both males and females at this age to prevent HPV-related cancers and diseases. The other options are not typically given to a child who is up to date on immunizations at age 11. Rotavirus vaccine is usually given in infancy, pneumococcal conjugate vaccine is given earlier in childhood, and hepatitis B vaccine is typically administered shortly after birth and during infancy. Therefore, the HPV vaccine is the appropriate choice for this scenario.
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A nurse is caring for a client who is taking allopurinol. Which of the following laboratory findings indicates the medication has been effective?
- A. Decreased triglycerides
- B. Decreased uric acid
- C. Increased albumin
- D. Increased potassium
Correct Answer: B
Rationale: The correct answer is B: Decreased uric acid. Allopurinol is used to treat high levels of uric acid in the blood, which can lead to conditions like gout. A decrease in uric acid levels indicates that the medication is effectively lowering the client's uric acid levels. Triglycerides (choice A) are not directly affected by allopurinol. Albumin (choice C) and potassium (choice D) levels are not typically influenced by allopurinol therapy.
A nurse is caring for a client who has a new prescription for lorazepam. For which of the following adverse effects should the nurse monitor?
- A. Urinary retention
- B. Dizziness
- C. Decreased appetite
- D. Hypertension
Correct Answer: B
Rationale: Rationale: The correct answer is B, dizziness, because lorazepam is a benzodiazepine that can cause central nervous system depression, leading to dizziness as a common adverse effect. Urinary retention (A) is not a common side effect of lorazepam. Decreased appetite (C) is not typically associated with lorazepam use. Hypertension (D) is not a common adverse effect of lorazepam. It is important to monitor for dizziness as it can affect the client's safety and mobility.
A nurse is evaluating the laboratory results of four clients. The nurse should report which of the following laboratory results 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 warfarin and an INR of 2.0 (0.8 to 1.1).
- C. A client who has a prescription for heparin and an aPTT of 65 seconds (30-40 seconds).
- D. A client who has a prescription for warfarin and an INR of 3.0 (0.8 to 1.1).
Correct Answer: A
Rationale: The correct answer is A. A client who has a prescription for heparin and an aPTT of 90 seconds (30-40 seconds) should be reported to the provider because the aPTT result is significantly above the therapeutic range, indicating a potential risk of bleeding due to excessive anticoagulation. Heparin therapy requires close monitoring of aPTT levels to ensure the medication's efficacy and safety. Reporting this result promptly to the provider allows for timely adjustment of the heparin dosage to prevent complications.
Choices B, C, and D are incorrect because they fall within or close to the desired therapeutic ranges for the respective medications. Therefore, they do not require immediate reporting to the provider as they suggest appropriate anticoagulation levels.
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.
A nurse is assisting in the care of a client admitted for an acetaminophen overdose. Which of the following prescriptions should the nurse anticipate implementing?
- A. Administer naloxone.
- B. Monitor amylase and lipase.
- C. Obtain a chest x-ray.
- D. Give acetylcysteine.
Correct Answer: D
Rationale: The correct answer is D: Give acetylcysteine. Acetylcysteine is the antidote for acetaminophen overdose as it helps replenish glutathione stores and prevent liver damage. Naloxone (A) is used for opioid overdose, not acetaminophen. Monitoring amylase and lipase (B) is for pancreatitis, not acetaminophen overdose. Obtaining a chest x-ray (C) is not necessary for acetaminophen overdose. Giving acetylcysteine (D) is the priority intervention for acetaminophen overdose to prevent liver toxicity.