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A nurse is reinforcing teaching about cyclosporine with a client who is postoperative following a kidney transplant. Which of the following statements indicates an understanding of the information?
- A. I can take ibuprofen to treat headaches.
- B. I will get out of bed slowly in the morning.
- C. I can expect hair loss when taking this medication.
- D. I will call my doctor if I have a sore throat.
Correct Answer: D
Rationale: The correct answer is D: "I will call my doctor if I have a sore throat." This statement indicates an understanding of the potential side effects of cyclosporine, one of which is immunosuppression leading to increased susceptibility to infections. By recognizing the importance of reporting a sore throat promptly, the client demonstrates awareness of the need for close monitoring and early intervention to prevent serious complications.
Incorrect choices:
A: Taking ibuprofen can interact with cyclosporine and is not recommended.
B: Getting out of bed slowly is a general precaution but not specific to cyclosporine.
C: Hair loss is not a common side effect of cyclosporine.
E, F, G: No information is provided for these choices.
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A nurse is preparing to administer an insulin injection for a client. Which of the following actions should the nurse take?
- A. Administer the insulin using a tuberculin syringe at a 15° angle.
- B. Rapidly inject the insulin using a 20-gauge 1-inch needle.
- C. Insert the needle into the right thigh at a 90° angle.
- D. Slowly inject the insulin using the Z-track method.
Correct Answer: C
Rationale: The correct answer is C: Insert the needle into the right thigh at a 90° angle. When administering insulin, the thigh is a recommended site for injection due to its larger muscle mass, which helps with consistent absorption. Inserting the needle at a 90° angle ensures proper depth for subcutaneous injection. This method also minimizes the risk of injecting into a blood vessel or reaching deeper tissues. Using the right thigh allows for rotation of injection sites, preventing lipodystrophy. Administering at a 90° angle promotes optimal absorption and minimizes discomfort for the client.
Choice A is incorrect because a tuberculin syringe is not typically used for insulin administration, and a 15° angle is too shallow for a subcutaneous injection. Choice B is incorrect as a 20-gauge needle is too large for insulin injections, which are typically administered with smaller gauge needles. Choice D is incorrect as the Z-track method is not used for insulin injections, and a slow
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.
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.
A nurse is caring for a client who is receiving an oral solution of codeine to suppress a nonproductive cough. Which of the following is the nurse's data collection priority following administration of this medication?
- A. Heart rate
- B. Respiratory rate
- C. Blood pressure
- D. Level of consciousness
Correct Answer: B
Rationale: The correct answer is B: Respiratory rate. Codeine is a central nervous system depressant that can cause respiratory depression as a side effect. Therefore, monitoring the client's respiratory rate is crucial to detect any signs of respiratory distress or suppression. This should be the nurse's priority to ensure the client's safety.
A: Heart rate may be affected by codeine, but respiratory rate is a more direct indicator of respiratory depression.
C: Blood pressure is not typically affected by codeine in the context of suppressing a cough.
D: Level of consciousness is important, but respiratory rate takes precedence as it directly reflects potential respiratory depression.
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.