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.
You may also like to solve these questions
The client recently has had a myocardial infarction. Which medications should the nurse anticipate the health-care provider recommending to prevent another heart attack?
- A. Vitamin K and a nonsteroidal anti-inflammatory drug.
- B. Vitamin E and a daily low-dose aspirin.
- C. Vitamin A and an anticoagulant.
- D. Vitamin B complex and an iron supplement.
Correct Answer: B
Rationale: Low-dose aspirin prevents platelet aggregation, reducing MI risk, per ACC/AHA guidelines. Vitamin E lacks evidence for secondary prevention; other options are irrelevant or contraindicated.
The nurse is administering diltiazem (Cardizem) to a client. Prior to administration, it is important for the nurse to assess which parameter?
- A. Temperature
- B. Blood pressure
- C. Vision
- D. Bowel sounds
Correct Answer: B
Rationale: Blood pressure. Diltiazem (Cardizem) is a calcium channel blocker that causes systemic vasodilation resulting in decreased blood pressure.
The nurse is providing education for a client with newly diagnosed tuberculosis. Which statement should be included in the information that is given to the client?
- A. Isolate yourself from others until you are finished taking your medication.'
- B. Follow up with your primary care provider in 3 months.'
- C. Continue to take your medications even when you are feeling fine.'
- D. Continue to get yearly tuberculin skin tests.'
Correct Answer: C
Rationale: The most important piece of information the tuberculosis client needs is to understand the importance of medication compliance, even if no longer experiencing symptoms. Clients are most infectious early in the course of therapy. The numbers of acid-fast bacilli are greatly reduced as early as 2 weeks after therapy begins.
The nurse is caring for a client with schizophrenia who has been treated with quetiapine (Seroquel) for 1 month. Today the client is increasingly agitated and complains of muscle stiffness. Which of these findings should be reported to the health care provider?
- A. Elevated temperature and sweating
- B. Decreased pulse and blood pressure
- C. Mental confusion and general weakness
- D. Muscle spasms and seizures
Correct Answer: A
Rationale: Elevated temperature and sweating. Neuroleptic malignant syndrome (NMS) is a rare disorder that can occur as a side effect of antipsychotic medications. It is characterized by muscular rigidity, tachycardia, hyperthermia, sweating, altered consciousness, autonomic dysfunction, and increase in CPK. This is a life-threatening complication.
A woman with a 28 week pregnancy is on the way to the emergency department by ambulance with a tentative diagnosis of abruptio placenta. Which should the nurse do first when the woman arrives?
- A. administer oxygen by mask at 100%
- B. start a second IV with an 18 gauge cannula
- C. check fetal heart rate every 15 minutes
- D. insert urethral catheter with hourly urine outputs
Correct Answer: A
Rationale: administer oxygen by mask at 100%. Administering oxygen in this situation would increase the circulating oxygen in the mother's circulation to the fetus's circulation. This action will minimize complications.