Nokea
A nurse working in an urgent care clinic is collecting data from a client who takes montelukast. Which of the following is an expected therapeutic effect of this medication?
- A. Improved peripheral vasodilation
- B. Reduced bronchial inflammation
- C. Neutralized gastric acid
- D. Increased WBC count
Correct Answer: B
Rationale: The correct answer is B: Reduced bronchial inflammation. Montelukast is a leukotriene receptor antagonist commonly used to treat asthma and allergic rhinitis. By blocking leukotrienes, it helps reduce bronchial inflammation, leading to improved breathing and decreased asthma symptoms. Other choices are incorrect because montelukast does not affect peripheral vasodilation, gastric acid levels, or WBC count. It is important for the nurse to recognize the expected therapeutic effects of medications to monitor and evaluate the client's response accurately.
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A nurse is preparing to administer erythromycin PO to a client who has an infection. The nurse checks the client's medical record and notes that the client has a severe allergy to penicillin. Which of the following actions should the nurse take?
- A. Request a different medication from the provider.
- B. Premedicate the client with diphenhydramine.
- C. Administer the medication to the client.
- D. Request a different route of administration from the provider.
Correct Answer: C
Rationale: Rationale: The correct action is to administer the medication to the client (Choice C) because erythromycin is not related to penicillin and is safe to use in clients with a penicillin allergy. Requesting a different medication (Choice A) may not be necessary as erythromycin is a suitable alternative. Premedicating with diphenhydramine (Choice B) is not indicated for a penicillin allergy. Requesting a different route of administration (Choice D) is unnecessary since the oral route is appropriate for erythromycin.
A nurse is collecting data from a client who is experiencing oxycodone toxicity. Which of the following findings should the nurse expect?
- A. Tachycardia
- B. Sedation
- C. Dilated pupils
- D. Tachypnea
Correct Answer: B
Rationale: The correct answer is B: Sedation. Oxycodone is an opioid that depresses the central nervous system, leading to symptoms such as sedation or drowsiness. This is because opioids like oxycodone bind to opioid receptors in the brain, causing a calming effect. Tachycardia (A) and dilated pupils (C) are more commonly associated with stimulant toxicity rather than opioid toxicity. Tachypnea (D) is not a typical finding in opioid toxicity as opioids tend to depress the respiratory system, causing respiratory depression instead.
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 caring for a client who has hypertension and has been taking hydrochlorothiazide. Which of the following laboratory values should the nurse evaluate?
- A. Coagulation studies
- B. Thyroid levels
- C. Complete blood count
- D. Serum electrolyte levels
Correct Answer: D
Rationale: The correct answer is D: Serum electrolyte levels. Hydrochlorothiazide is a diuretic that can lead to electrolyte imbalances, such as hypokalemia and hyponatremia. Monitoring serum electrolyte levels is crucial to prevent complications like arrhythmias. Coagulation studies (A) are not typically affected by hydrochlorothiazide. Thyroid levels (B) are unrelated to this medication. Complete blood count (C) is not directly impacted by hydrochlorothiazide. Thus, evaluating serum electrolyte levels is the most relevant and essential assessment in this scenario.
A nurse is preparing to administer an IM injection to a client who has gonorrhea. Which of the following actions should the nurse take?
- A. Use the Z-track technique to administer the medication.
- B. Administer the medication with a 27-gauge 1/2-inch needle.
- C. Inject the medication at least 5 cm (2 in) from the umbilicus.
- D. Give the medication without aspirating prior to injection.
Correct Answer: A
Rationale: The correct answer is A: Use the Z-track technique to administer the medication. This technique helps prevent leakage of the medication into surrounding tissues by sealing the medication in the muscle. The Z-track method involves pulling the skin laterally before injecting the medication, then releasing the skin after the injection. This creates a zig-zag path that closes after the needle is withdrawn, reducing the risk of irritation or staining at the injection site. Choice B is incorrect because the needle size for IM injections in adults is typically 22-25 gauge and 1-1.5 inches long. Choice C is incorrect as IM injections should be administered at least 2.5 cm (1 inch) away from the umbilicus. Choice D is incorrect because aspiration (pulling back on the plunger to check for blood return) is not recommended for IM injections due to the risk of tissue trauma.