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A nurse is reinforcing teaching for a client who has angina pectoris and a new prescription to apply a nitroglycerin transdermal patch daily. Which of the following instructions should the nurse give the client?
- A. Use an old patch with medication residue on the inside and discard it in a closed receptacle.
- B. Keep a nitroglycerin patch in place for 72 hours before replacing.
- C. Apply the patch to a hairy area of the skin for better adherence.
- D. Cleanse the skin before applying a nitroglycerin patch.
Correct Answer: D
Rationale: The correct answer is D - Cleanse the skin before applying a nitroglycerin patch. This instruction is crucial to ensure proper absorption of the medication and prevent skin irritation. Cleansing the skin removes dirt, oils, and sweat, allowing the patch to adhere properly and deliver the medication effectively. Using an old patch (A) can lead to inconsistent dosing and decreased effectiveness. Keeping the patch in place for 72 hours (B) can cause skin irritation and decrease medication potency. Applying the patch to a hairy area (C) may reduce adherence and interfere with proper contact with the skin. Therefore, instructing the client to cleanse the skin before application is the most appropriate choice.
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Which medication should the nurse have available to reverse heparin's effects for a client who has thrombophlebitis and is receiving a continuous heparin infusion?
- A. Protamine sulfate.
- B. Deferoxamine.
- C. Sodium polystyrene sulfonate.
- D. Acetylcysteine.
Correct Answer: A
Rationale: The correct answer is A: Protamine sulfate. Protamine sulfate is the antidote for heparin, which works by binding to heparin molecules to neutralize its anticoagulant effects. It is used to reverse the effects of heparin in cases of overdose or if immediate reversal is needed. Deferoxamine (B) is used for iron poisoning, sodium polystyrene sulfonate (C) for hyperkalemia, and acetylcysteine (D) for acetaminophen overdose.
A nurse in the emergency department is assisting with the care of a client who has a deep laceration on her left lower forearm and is bleeding heavily from the wound. Which of the following actions should the nurse take first?
- A. Apply a tourniquet just above the wound.
- B. Place the client in a modified Trendelenburg position.
- C. Apply pressure directly to the wound.
- D. Settle the client in a reclining position.
Correct Answer: C
Rationale: The correct action is to apply pressure directly to the wound first. This is crucial to control the bleeding and prevent further blood loss. Applying pressure helps to promote clotting and reduce the risk of hypovolemic shock. It is the immediate and most effective intervention to manage the situation.
Choice A (Apply a tourniquet just above the wound) is incorrect because tourniquets should be used as a last resort due to the risk of tissue damage and potential complications.
Choice B (Place the client in a modified Trendelenburg position) is incorrect as this position is not recommended for patients with bleeding as it can increase intracranial pressure and worsen the situation.
Choice D (Settle the client in a reclining position) is incorrect because the priority is to control the bleeding first before adjusting the client's position.
A nurse is caring for a client who has a prescription for digoxin 0.25 mg PO daily. The amount available is digoxin 0.125 mg tablet. How many tablets should the nurse administer per dose? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.).
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: B
Rationale: To calculate how many tablets to administer, divide the prescribed dose by the available tablet strength. 0.25 mg ÷ 0.125 mg = 2 tablets. Round to the nearest whole number, which is 2. Therefore, the nurse should administer 2 tablets per dose. Other choices are incorrect as they do not result from the correct calculation method.
A nurse is teaching the parents of a child who has diabetes mellitus about the manifestations of hypoglycemia. Which of the following manifestations should the nurse include in the teaching?
- A. Dry mucous membranes.
- B. Polyuria.
- C. Poria.
- D. Bradycardia.
Correct Answer: D
Rationale: The correct answer is D: Bradycardia. Hypoglycemia can lead to decreased heart rate due to inadequate glucose supply to the heart. This can result in bradycardia. Dry mucous membranes (A) are more indicative of dehydration. Polyuria (B) is excessive urination, which is not a common manifestation of hypoglycemia. "Poria" (C) is not a recognized medical term. Therefore, the correct manifestation to include in teaching about hypoglycemia in a child with diabetes mellitus is bradycardia.
A nurse in a provider's office is collecting data from a client who has hypothyroidism. Which of the following should the nurse expect?
- A. Bradycardia.
- B. Moist skin.
- C. Blurred vision.
- D. Insomnia.
Correct Answer: A
Rationale: The correct answer is A: Bradycardia. In hypothyroidism, there is a decrease in thyroid hormone production, leading to a slowed metabolism. This results in bradycardia, or a slow heart rate, as the thyroid hormone plays a role in regulating heart function. Moist skin (B), blurred vision (C), and insomnia (D) are not typically associated with hypothyroidism; instead, dry skin, vision changes, and fatigue are more common symptoms.