Nokea
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.
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A nurse is caring for a client who has been taking epoetin alfa for 3 months. Which of the following laboratory tests should the nurse monitor to determine the effectiveness of the medication?
- A. Troponin
- B. Thyroxine (T4)
- C. Aspartate aminotransferase (AST)
- D. Hgb
Correct Answer: D
Rationale: The correct answer is D: Hgb (hemoglobin). Epoetin alfa is a medication used to stimulate red blood cell production. Monitoring hemoglobin levels is crucial to assess the effectiveness of the medication in increasing red blood cell count. Hemoglobin reflects the oxygen-carrying capacity of red blood cells, indicating if the medication is addressing the underlying anemia. Troponin (A) is used to assess heart muscle damage, not relevant in this case. Thyroxine (B) reflects thyroid function, not related to epoetin alfa therapy. Aspartate aminotransferase (AST) (C) is a liver enzyme, not relevant for monitoring this medication's efficacy.
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.
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.
A nurse is collecting data from a client who has been taking carbamazepine. Which of the following is an adverse effect of carbamazepine and should be reported to the provider?
- A. Sore throat
- B. Increased salivation
- C. Urge incontinence
- D. Gingivitis
Correct Answer: A
Rationale: The correct answer is A: Sore throat. Carbamazepine can cause agranulocytosis, a serious condition characterized by a decrease in white blood cells, leading to symptoms like sore throat. This is a potentially life-threatening adverse effect that should be reported to the provider immediately. Increased salivation (choice B), urge incontinence (choice C), and gingivitis (choice D) are not common adverse effects of carbamazepine and do not require immediate reporting.
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.