Nokea
A nurse is reinforcing teaching with a client who has a new prescription for nitroglycerin transdermal patches to treat angina. The nurse should inform the client that which of the following manifestations is an adverse effect of the medication?
- A. Headache
- B. Polyuria
- C. Ringing in the ears
- D. Increased blood pressure
Correct Answer: A
Rationale: The correct answer is A: Headache. Nitroglycerin transdermal patches can cause headaches as an adverse effect due to vasodilation leading to increased blood flow to the brain. This is a common side effect that may occur in patients using nitroglycerin. Polyuria (B) and ringing in the ears (C) are not common side effects of nitroglycerin. Increased blood pressure (D) is not an adverse effect of nitroglycerin; in fact, nitroglycerin decreases blood pressure by dilating blood vessels.
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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
Vital Signs
Laboratory Results
0800:
Client is admitted with a 3-day history of abdominal cramps and diarrhea of 4 to 5 liquid stools per day.
Client was taking amoxicillin/clavulanate 875 mg PO every 12 hr for 10 days for a respiratory tract infection. Antibiotics completed 7 days ago.
Bilateral breath sounds clear and present throughout.
Abdomen soft, distended with hyperactive bowel sounds audible in all 4 quadrants.
Stool is watery and contains mucous. Stool sent for culture.
The nurse should first address the client's ___ followed by the client's ___. (Options: Hgb level, Blood pressure, temperature, Hct level, abdominal findings, potassium level)
- A. Hgb level
- B. Blood pressure
- C. temperature
- D. Hct level
- E. abdominal findings
- F. potassium level
Correct Answer: B,F
Rationale: Action to Take: B, F; Potential Condition: Hypovolemia; Parameter to Monitor: Blood Pressure, Potassium Level.
Rationale:
1. Blood pressure should be addressed first to assess perfusion status and hemodynamic stability.
2. Potassium level should be monitored next due to potential electrolyte imbalances in hypovolemia.
3. Hgb, Hct, and abdominal findings are important but secondary to addressing perfusion and electrolyte balance.
4. Temperature is not typically the initial concern in hypovolemia.
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 reinforcing teaching with the parents of a 13-month-old child following administration of the measles mumps rubella (MMR) Immunization. Which of the following statements by the nurse is appropriate?
- A. Your child will receive another MMR immunization and the hepatitis B immunization at 3 years of age.
- B. Your child will receive two more MMR immunizations over the next 2 years.
- C. Your child will receive another MMR immunization at 4 to 6 years of age.
- D. Your child will have an MMR titer taken to determine the need for further immunizations.
Correct Answer: C
Rationale: The correct answer is C because at 13 months, the child receives the first dose of MMR vaccine. The second dose is usually given at 4 to 6 years of age to ensure long-term immunity. Option A is incorrect as hepatitis B is not typically given at 3 years of age with MMR. Option B is incorrect because only one more dose of MMR is usually needed. Option D is incorrect because titers are not routinely done for MMR vaccine.
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.