Nokea
The client diagnosed with angina must receive a two (2)-inch nitroglycerin paste (Nitro-Bid) application. Which interventions should the nurse implement? Select all that apply.
- A. Wear gloves when administering.
- B. Remove the old Nitro-Bid paper.
- C. Apply the paper on a hairy spot.
- D. Put medication only on the legs.
- E. Report any headache to the HCP.
Correct Answer: A,B
Rationale: Gloves prevent nurse absorption, and removing old paste ensures accurate dosing. Hairy spots reduce adhesion, leg-only application is incorrect, and headaches are expected.
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To which client would the nurse question administering the osmotic diuretic mannitol (Osmitrol)?
- A. The client with 4+ pitting pedal edema.
- B. The client with decorticate posturing.
- C. The client with widening pulse pressure.
- D. The client with a positive doll's eye test.
Correct Answer: C
Rationale: Widening pulse pressure suggests increased intracranial pressure, a contraindication for mannitol due to potential brain herniation. Edema or neurological signs are indications.
The client diagnosed with diabetes insipidus is receiving vasopressin intranasally. Which assessment data indicate the medication is effective?
- A. The client reports being able to breathe through the nose.
- B. The client complains of being thirsty all the time.
- C. The client has a blood glucose of 99 mg/dL.
- D. The client is urinating every three (3) to four (4) hours.
Correct Answer: D
Rationale: Vasopressin reduces polyuria in diabetes insipidus; urination every 3–4 hours indicates effectiveness. Nasal breathing, thirst, or glucose are unrelated.
An adult client had an abdominal hysterectomy this morning. Meperidine HCl (Demerol) 75 mg IM q3-4h PRN for pain is ordered. At 9:00 P.M., she complains of lower abdominal pain. She was last medicated at 5:45 P.M. What is the most appropriate initial action for the nurse to take?
- A. Offer her a bed pan and a back rub
- B. Reposition her
- C. Administer meperidine HCl 75 mg IM
- D. Encourage her to perform relaxation and breathing exercises
Correct Answer: C
Rationale: The last dose was over 3 hours ago, within the PRN order. Administering meperidine is appropriate for pain relief.
A client with anemia has a new prescription for ferrous sulfate. In teaching the client about diet and iron supplements, the nurse should emphasize that absorption of iron is enhanced if taken with which substance?
- A. Acetaminophen
- B. Orange juice
- C. Low fat milk
- D. An antacid
Correct Answer: B
Rationale: Orange juice. Ascorbic acid enhances the absorption of iron.
A client is ordered atropine to be administered preoperatively. Which physiological effect should the nurse monitor for?
- A. Elevate blood pressure
- B. Drying up of secretions
- C. Reduce heart rate
- D. Enhance sedation
Correct Answer: B
Rationale: Drying up of secretions. Atropine dries secretions which may get in the way during the operative procedure.