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A nurse is reinforcing teaching with a young adult client who has a new prescription for ear drops. Which of the following instructions should the nurse include?
- A. Chill the medication prior to instillation.
- B. Press a cotton ball firmly in ear canal after administering drops.
- C. Pull the pinna up and back to administer medication.
- D. Place an applicator into the ear canal to instill drops.
Correct Answer: C
Rationale: The correct answer is C: Pull the pinna up and back to administer medication. This instruction is correct because pulling the pinna up and back helps straighten the ear canal in adults, allowing the drops to be instilled properly. This technique ensures that the medication reaches the desired target area for optimal effectiveness.
Explanation of other choices:
A: Chilling the medication is not necessary and can cause discomfort to the client.
B: Pressing a cotton ball firmly in the ear canal can prevent the drops from reaching the ear canal.
D: Placing an applicator into the ear canal can cause injury or damage to the ear canal and eardrum.
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A nurse is caring for a client who has Graves' disease and is to start therapy with propylthiouracil. The nurse should expect which of the following outcomes?
- A. Decreased heart rate
- B. Decreased WBC count
- C. Increased Hgb
- D. Increased blood pressure
Correct Answer: A
Rationale: The correct answer is A: Decreased heart rate. Propylthiouracil is an antithyroid medication used to treat hyperthyroidism in conditions like Graves' disease. It works by inhibiting the production of thyroid hormones. Since hyperthyroidism can cause an increased heart rate due to the excess thyroid hormones, the expected outcome of propylthiouracil therapy is a decreased heart rate as it helps normalize thyroid hormone levels. The other choices are incorrect because propylthiouracil does not directly affect WBC count (B), Hgb levels (C), or blood pressure (D) in the context of treating hyperthyroidism.
A nurse is collecting data from a client who is taking ferrous sulfate. The nurse should report which of the following findings as an adverse effect of this medication?
- A. Tinnitus
- B. Hot flashes
- C. Diplopia
- D. Epigastric pain
Correct Answer: D
Rationale: The correct answer is D: Epigastric pain. Ferrous sulfate is an iron supplement commonly known to cause gastrointestinal side effects, such as epigastric pain, nausea, and constipation. The rationale behind this is that iron can irritate the stomach lining, leading to discomfort or pain in the epigastric region. Tinnitus (A), hot flashes (B), and diplopia (C) are not typically associated with ferrous sulfate administration. Tinnitus is more commonly linked to aspirin toxicity, hot flashes are often related to hormonal changes, and diplopia is a symptom of various neurological conditions. Thus, the nurse should report epigastric pain as a potential adverse effect of ferrous sulfate.
Provider Prescriptions: Tetracycline 500 mg PO twice daily; Vital Signs Initial visit: Temperature 37.1° C (98.8° F), Heart rate 82/min, Blood pressure 118/76 mm Hg, Respiratory rate 16/min, SpO2 99% on room air; Current visit: Temperature 37.5° C (99.5° F), Heart rate 84/min, Blood pressure 122/72 mm Hg, Respiratory rate 18/min, SpO2 99% on room air; History and Physical Initial visit: Client is a 20-year-old female who presents with report of worsening acne over the past few months. Severe inflammatory acne noted over face, neck, and upper back. Client has no significant medical or surgical history. Discussed skin hygiene and use of over-the-counter acne treatments. Current visit: Client reports no improvement in acne since prior visit 2 months ago. Client states they have been gently washing their skin twice daily and using acne treatments as recommended. Client states they are self-conscious and avoids certain social activities. No change in acne noted on assessment. Tetracycline prescribed. Will have the client return to the clinic in 4 weeks.
The nurse should identify that the client is at risk for developing ________and _________
- A. Increased cholesterol level
- B. Gastridium difficite-associated diarrhea
- C. Elevated blood glucose level
- D. Gallstones
- E. Vaginal yeast infection
Correct Answer: B, E
Rationale: Correct Answer: B, E
Rationale:
1. Choice B: Gastridium difficile-associated diarrhea is a risk for clients on antibiotics, disrupting gut flora balance.
2. Choice E: Vaginal yeast infection risk increases with antibiotic use, disrupting vaginal flora.
Summary:
- A, C, D: These choices are not directly related to antibiotic use or disruption of flora balance.
- B, E: Antibiotics can lead to imbalances in gut and vaginal flora, increasing the risk for these conditions.
A nurse is reinforcing teaching with the parents of a 1-year-old client following the administration of the measles, mumps, and rubella virus vaccine (MMR). Which of the following adverse effects should the nurse instruct the parents to report to the provider?
- A. Glandular swelling around the jaw
- B. Redness around the injection site
- C. Temperature 37.3° C (99.2° F)
- D. Shortness of breath
Correct Answer: D
Rationale: The correct answer is D: Shortness of breath. Shortness of breath can indicate a severe allergic reaction or anaphylaxis, which is a rare but serious adverse effect of the MMR vaccine. It is crucial to report this immediately to the healthcare provider for prompt evaluation and management to prevent any complications.
A: Glandular swelling around the jaw is a common and mild side effect of the MMR vaccine, typically resolving on its own and not requiring immediate medical attention.
B: Redness around the injection site is a common and expected reaction to the vaccine, usually resolving without intervention.
C: A temperature of 37.3° C (99.2° F) is a low-grade fever, which can be a normal response to vaccination and typically does not require urgent medical attention.
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. Inject the medication into the subcutaneous tissue of your abdomen.
- C. Take the medication at bedtime.
- D. Discard excess medication after 60 days.
Correct Answer: B
Rationale: The correct answer is B: Inject the medication into the subcutaneous tissue of your abdomen. Exenatide is a medication used to treat type 2 diabetes and is administered by subcutaneous injection. Injecting it into the abdomen allows for better absorption. It is important for the nurse to instruct the client on the correct administration technique to ensure the medication is effective.
Incorrect choices:
A: Contact the provider if you experience unexplained muscle pain - Although monitoring for side effects is important, muscle pain is not a common side effect of exenatide.
C: Take the medication at bedtime - Exenatide is typically taken before meals, not at bedtime.
D: Discard excess medication after 60 days - Exenatide must be refrigerated and has a shorter shelf life once opened, typically 30 days, not 60.