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A nurse is reinforcing discharge teaching with a client who has a new diagnosis of type 2 diabetes mellitus and a prescription for exenatide. Which of the following instructions should the nurse include in the teaching?
- A. Contact the provider if you experience unexplained muscle pain.
- B. Take the medication at bedtime.
- C. Discard excess medication after 60 days.
- D. Inject the medication into the subcutaneous tissue of your abdomen.
Correct Answer: D
Rationale: The correct answer is D: Inject the medication into the subcutaneous tissue of your abdomen. Exenatide is a medication that is administered through subcutaneous injection, typically into the abdomen. This is the correct route of administration to ensure proper absorption and effectiveness of the medication. Option A is incorrect as it is not directly related to the administration of exenatide. Option B is incorrect because exenatide is usually taken before meals, not at bedtime. Option C is incorrect as the disposal timeline for exenatide is typically shorter than 60 days.
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A nurse is monitoring a client who is receiving a transfusion of packed RBCs. The nurse should identify which of the following findings as an indication of a febrile nonhemolytic reaction?
- A. Dyspnea
- B. Urticaria
- C. Chills
- D. Vomiting
Correct Answer: C
Rationale: The correct answer is C: Chills. A febrile nonhemolytic reaction during a blood transfusion is characterized by the sudden onset of chills and fever, usually within the first 15 minutes to 2 hours of the transfusion. This reaction is caused by the recipient's antibodies reacting to donor leukocytes. Dyspnea (A), urticaria (B), and vomiting (D) are more indicative of other transfusion reactions such as an allergic reaction, hemolytic reaction, or bacterial contamination, respectively.
A nurse is planning to administer a tuberculin skin test to a client who has had an exposure to tuberculosis. Which of the following actions should the nurse plan to take?
- A. Inject 0.3 to 0.5 mL of the solution.
- B. Select an injection site that is free of scar tissue.
- C. Hold the needle at a 30° angle during injection.
- D. Massage the site following the injection.
Correct Answer: B
Rationale: Correct Answer: B - Select an injection site that is free of scar tissue.
Rationale: Selecting an injection site that is free of scar tissue is crucial for accurate tuberculin skin test results. Scar tissue can interfere with the test by affecting the absorption of the solution and potentially leading to false results. Choosing a site free of scar tissue ensures proper administration and interpretation of the test.
Incorrect Choices:
A: Injecting 0.3 to 0.5 mL of the solution is not the key factor in ensuring accurate results. The volume to be injected may vary based on the specific test kit used, but the injection site's condition is more critical.
C: Holding the needle at a 30° angle is not a standard requirement for administering a tuberculin skin test. The angle of injection may vary based on the client's skin thickness and other factors.
D: Massaging the site following the injection is unnecessary and could potentially lead to inaccurate results. Massaging can alter the distribution
A nurse is collecting data from a client who has been taking methimazole for 2 months for the treatment of a thyroid imbalance. Which of the following findings indicates that the medication is effective?
- A. Weight gain
- B. Decreased menstrual flow
- C. Clear breath sounds
- D. Increased libido
Correct Answer: A
Rationale: The correct answer is A: Weight gain. Methimazole is used to treat hyperthyroidism, which often causes weight loss due to increased metabolism. If the medication is effective, the client's thyroid hormone levels should normalize, leading to a potential reversal of weight loss and even weight gain. Decreased menstrual flow (B) and increased libido (D) are not direct indicators of methimazole effectiveness. Clear breath sounds (C) could indicate improved respiratory status but are not specific to thyroid function.
A nurse is caring for a client who has a new prescription for a nitroglycerin transdermal patch. Which of the following actions should the nurse take?
- A. Take the patch off prior to bathing the client.
- B. Monitor for hypertension after application of the patch.
- C. Rotate the application sites of the patch.
- D. Remove the patch every 24 hr
Correct Answer: C
Rationale: The correct answer is C: Rotate the application sites of the patch. This is important to prevent skin irritation and tolerance development. By rotating the sites, the nurse ensures consistent drug absorption and effectiveness. Choice A is incorrect because removing the patch prior to bathing can disrupt drug delivery. Choice B is incorrect as nitroglycerin typically causes hypotension, not hypertension. Choice D is incorrect as nitroglycerin patches are usually left on for 12-14 hours and then replaced with a new patch.
A nurse is preparing to administer acetaminophen 10 mg/kg PO every 6 hr to a toddler who weighs 26.4 lb. Available is acetaminophen 80 mg/0.8 mL liquid. How many mL should the nurse administer with each dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
- A. 1.2
Correct Answer: A
Rationale: To calculate the correct dose, first convert the toddler's weight from pounds to kilograms: 26.4 lb / 2.2 = 12 kg. Then calculate the dose: 10 mg/kg * 12 kg = 120 mg per dose. Next, determine how many mL of the liquid acetaminophen contain 120 mg: 80 mg/0.8 mL = 120 mg/X mL. Cross multiply to find X = 1.2 mL. Therefore, the correct answer is A: 1.2 mL. Other choices are incorrect as they do not align with the calculated dose based on the toddler's weight and the concentration of the liquid form of acetaminophen available.