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A nurse is reinforcing teaching about phenytoin with a client who had a tonic-clonic seizure. Which of the following information should the nurse include in the teaching?
- A. Taking ginkgo biloba increases phenytoin levels.
- B. Taking phenytoin diminishes potassium levels.
- C. Monitor for gingival hyperplasia.
- D. Minimize exposure to sunlight.
Correct Answer: C
Rationale: The correct answer is C: Monitor for gingival hyperplasia. This is important because phenytoin can cause gingival overgrowth, leading to oral health issues. The nurse should educate the client to maintain good oral hygiene and visit the dentist regularly for check-ups.
A: Taking ginkgo biloba increases phenytoin levels - This statement is incorrect. Ginkgo biloba is known to interact with certain medications, but it does not specifically increase phenytoin levels.
B: Taking phenytoin diminishes potassium levels - This statement is incorrect. Phenytoin does not directly affect potassium levels. It is more likely to cause issues with calcium and vitamin D metabolism.
D: Minimize exposure to sunlight - This statement is incorrect. While some antiepileptic medications can increase sensitivity to sunlight, phenytoin is not typically associated with this side effect.
Overall, monitoring for gingival hyperplasia is the most relevant information for the client
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A nurse is collecting data from a client who states she recently started taking garlic as an herbal supplement. The nurse should advise the client to stop taking garlic due to a potential reaction with which of the following client medications?
- A. Dicloxacillin
- B. Warfarin
- C. Esomeprazole
- D. Hydrochlorothiazide
Correct Answer: B
Rationale: The correct answer is B: Warfarin. Garlic can interact with warfarin, an anticoagulant, potentially increasing the risk of bleeding due to its antiplatelet effects. Garlic can enhance the effects of warfarin, leading to an increased risk of bleeding complications. Dicloxacillin (A) is an antibiotic, Esomeprazole (C) is a proton pump inhibitor, and Hydrochlorothiazide (D) is a diuretic, none of which have significant interactions with garlic.
A nurse is preparing to administer 17,000 units heparin subcutaneously. Available is heparin 20,000 units/mL. How many mL should the nurse administer? (Round the answer to the nearest hundredth. Use a leading zero if applicable. Do not use a trailing zero.)
- A. 0.85
Correct Answer: A
Rationale: To calculate the mL of heparin needed, use the formula: Amount needed (17,000 units) ÷ Concentration of heparin (20,000 units/mL) = mL to administer. 17,000 ÷ 20,000 = 0.85 mL (Round to the nearest hundredth). Therefore, the correct answer is A (0.85 mL). Other choices are incorrect as they do not result from the correct calculation.
A nurse in an influenza clinic is collecting data from four clients. Which of the following clients should the nurse identify as having a contraindication for receiving the live attenuated form of the influenza vaccine?
- A. An adolescent who received a new tattoo last week
- B. A client is at 27 weeks of gestation
- C. A client who is about to travel to a different country
- D. A school-age child who has rhinitis
Correct Answer: B
Rationale: The correct answer is B - A client at 27 weeks of gestation. Pregnant individuals are contraindicated to receive live attenuated influenza vaccine due to theoretical risk to the fetus. This is because live vaccines are not recommended during pregnancy. Choice A is incorrect as a recent tattoo does not contraindicate the vaccine. Choice C is incorrect as travel plans do not affect the decision to administer the vaccine. Choice D is incorrect as rhinitis is not a contraindication.
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 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