Nokea
A nurse Rover medical-surgical unit is caring for a client who asks to review his medical record. Which of the following responses should the nurse make?
- A. You will have to submit a written request for access to your record.
- B. We will provide you a copy of your records when we are preparing you for discharge.
- C. Sorry, but you do not have the time to read your chart.
- D. I can set up a time for you to meet with your provider to go over your medical record.
Correct Answer: D
Rationale: The correct answer is D. The nurse should set up a time for the client to meet with their provider to go over their medical record. This response respects the client's right to access their medical information in a timely and organized manner, ensuring they can fully understand their health status and treatment plan. Option A delays the process with unnecessary paperwork. Option B limits access to records only at discharge. Option C dismisses the client's request. Options E, F, and G are irrelevant.
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The physician orders vancomycin hydrochloride 2 g/day by mouth in 4 divided doses. The pharmacy fills the client's prescription with 500 mg vancomycin hydrochloride capsules. The nurse should instruct the client to take______capsule(s) per dose.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: To calculate how many capsules to take per dose, divide the total daily dose (2 g) by the strength of each capsule (500 mg).
1. Convert 2 g to mg: 2 g = 2000 mg
2. Divide 2000 mg by 500 mg per capsule: 2000 mg / 500 mg = 4 capsules per day
3. Since the prescription is to be taken in 4 divided doses, the client should take 1 capsule per dose.
Summary:
B: Incorrect - Not the correct calculation based on the dose and capsule strength.
C: Incorrect - Not the correct calculation based on the dose and capsule strength.
D: Incorrect - Not the correct calculation based on the dose and capsule strength.
E: Incorrect - Not the correct calculation based on the dose and capsule strength.
F: Incorrect - Not the correct calculation based on the dose and capsule strength.
G: Incorrect - Not the correct calculation
A nurse is reinforcing teaching with a client who is to start subcutaneous heparin. Which of the following information should the nurse include in the teaching?
- A. Use a soft-bristled toothbrush.
- B. Inject the medication deep into the thigh muscle.
- C. Expect stools to become black and tarry.
- D. Easy bruising indicates the medication is effective.
Correct Answer: A
Rationale: The correct answer is A: Use a soft-bristled toothbrush. When starting subcutaneous heparin, it is important to minimize the risk of bleeding. Using a soft-bristled toothbrush helps prevent gum bleeding. Choice B is incorrect because heparin is typically injected into the subcutaneous tissue, not deep into the muscle. Choice C is incorrect because black, tarry stools are a sign of gastrointestinal bleeding, not a side effect of heparin. Choice D is incorrect because easy bruising is not an indication of heparin's effectiveness, but rather a side effect indicating a need to adjust the dosage.
A nurse is preparing to administer heparin subcutaneously to a client who has deep vein thrombosis. Which of the following actions should the nurse take?
- A. Insert the needle at a 90-degree angle.
- B. Massage the injection site after administering the heparin.
- C. Prepare for a blood test prior to injecting the heparin.
- D. Select a 22-gauge needle for heparin administration.
Correct Answer: A
Rationale: Correct Answer: A: Insert the needle at a 90-degree angle.
Rationale: When administering heparin subcutaneously, the nurse should insert the needle at a 90-degree angle to ensure proper delivery of the medication into the subcutaneous tissue. This angle allows for optimal absorption and effectiveness of the medication. Additionally, it minimizes the risk of injecting the medication into muscle tissue, which could lead to complications.
Summary of other choices:
B: Massaging the injection site after administering heparin is not recommended as it can cause bruising or discomfort.
C: There is no need to prepare for a blood test prior to injecting heparin subcutaneously.
D: A 22-gauge needle is too large for subcutaneous injection and can cause pain and tissue damage.
A nurse is reviewing laboratory data from a client who has a pulmonary embolism and is receiving IV heparin. Which of the following findings should the nurse report to the provider?
- A. Patient's platelets 100,000.
- B. Prothrombin time (PT) 12 seconds.
- C. Thrombin time (TT) 55 seconds.
- D. Hematocrit 35%.
Correct Answer: A
Rationale: The correct answer is A: Patient's platelets 100,000. In a client receiving IV heparin for a pulmonary embolism, a platelet count of 100,000 indicates potential heparin-induced thrombocytopenia, a serious adverse effect that can lead to thrombosis. Thrombocytopenia increases the risk of bleeding. This finding needs immediate attention from the provider to prevent complications. The other choices are incorrect because B (PT) and C (TT) are not directly related to heparin therapy monitoring, and D (Hematocrit) does not indicate a potential adverse effect of heparin therapy like thrombocytopenia does.
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. Remove the used patch with medication areas to the inside and discard it in a closed receptacle.
- B. Keep the current nitroglycerin patch in place for 24 hours per day.
- C. Cleanse the excess hair from the skin before applying a nitroglycerin patch.
- D. Apply a second patch in place if angina pain occurs.
Correct Answer: A
Rationale: The correct answer is A: Remove the used patch with medication areas to the inside and discard it in a closed receptacle. This instruction is crucial as it ensures proper disposal to prevent accidental exposure to others. Removing the patch with the medication area inside reduces the risk of skin irritation. Keeping the patch in a closed receptacle prevents animals or children from coming into contact with the medication.
Choice B is incorrect because the patch should be applied for a specific duration, typically around 12-14 hours, not 24 hours. Choice C is unnecessary as excess hair does not affect the patch's efficacy. Choice D is dangerous as applying a second patch without medical guidance can lead to overdose.