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The client with ulcerative colitis is started on sulfasalazine. The nurse overhears the client talking with family members about sulfasalazine and recognizes the need for more teaching when the client makes which statement?
- A. I'll be taking sulfasalazine to help control my diarrhea.
- B. Sulfasalazine will decrease the inflammation in my colon.
- C. After a year of taking sulfasalazine, I'll be cured of the disease.
- D. Sulfasalazine will help to prevent exacerbations of my disease.
Correct Answer: C
Rationale: A: Sulfasalazine reduces inflammation and thereby will reduce the number of diarrheal stools. B: Sulfasalazine, commonly used to treat ulcerative colitis, decreases inflammation in the colon. C: This statement indicates the client needs additional teaching. Ulcerative colitis is a chronic illness. Sulfasalazine (Azulfidine) does not cure ulcerative colitis; the only cure is a total proctocolectomy. D: Sulfasalazine reduces inflammation and thereby will reduce the incidence of flare-ups from ulcerative colitis.
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The initial treatment regimen of isoniazid, rifampin, and ethambutol is prescribed for the adolescent who has a positive tuberculin skin test. The client confides that she thinks she may be pregnant and asks if she should be taking these medications. Which rationale should be the basis for the nurse's response?
- A. These drugs cross the placental barrier, and treatment should be withheld until the postpartum period.
- B. The medications should be taken, but the diagnosis is an indication for termination of the pregnancy.
- C. The medications should be postponed because the risk for hepatitis is greatly increased in the intrapartum period.
- D. The medications should be taken; untreated TB represents a far greater hazard to the pregnant woman and her fetus.
Correct Answer: D
Rationale: A: The medications do not cross the placental barrier, so treatment should not be withheld. B: Administering antituberculosis medications would not be an indication for termination of pregnancy because the medications are safe during pregnancy. C: The risk of hepatitis is slightly increased with the use of antituberculosis medications in pregnant women; however, the benefits of treatment strongly outweigh postponement of treatment. D: Infants born to women with untreated TB may be of lower birth weight, but rarely would the infant acquire congenital TB. Isoniazid (Nydrazid), rifampin (Rifadin), and ethambutol (Myambutol) are all considered safe for use in pregnancy.
The HCP prescribes haloperidol 4 mg tid oral liquid for the client diagnosed with schizophrenia. How many milliliters should the nurse administer from a bottle labeled “haloperidol 2 mg/mL†for each dose?
Correct Answer: 2
Rationale: Calculation: 4 mg/ 2 mg/mL = 2 mL per dose.
The nurse observes a colleague about to administer an IM injection to the 12-month-old. Which intervention requires the nurse to intervene?
- A. Prepares to give no more than 2 mL of fluid
- B. Plans to give the injection using a 1-inch needle
- C. Plans to give the injection in the dorsal gluteal site
- D. Plans to give the injection after applying lidocaine/prilocaine cream
Correct Answer: C
Rationale: A: No more than 2 mL of fluid should be injected into a muscle. B: The appropriate needle length for an IM injection for children ages 2 to 12 months is 1 inch and 1% inch for toddlers. C: Use of the dorsal gluteal site is not recommended due to a high risk of nerve damage. D: Use of lidocaine/prilocaine cream (EMLA) to numb the area is suggested when time allows but is not required.
The LPN needs to determine the client's respiratory rate. What is the best technique to do this?
- A. Tell the client you need to count their respiratory rate.
- B. Subtly watch the client from across the room when they are doing an activity.
- C. Ask the client to sit still for 30 seconds.
- D. Count respirations while pretending to check the client's pulse.
Correct Answer: D
Rationale: You should not tell the client you are counting their respirations, as this may cause them to alter their breathing pattern. Pretending to check a pulse allows you to get close to the client without cluing them in to what you are assessing. Standing across the room is not the best way to assess for respirations as they may be difficult to see.
Which spot is the safest place to administer an IM injection to an infant? Select the correct corresponding letter from the attached graphic.
- A. C
- B. B
- C. A
- D. D
Correct Answer: B
Rationale: The vastus lateralis muscle, highlighted by the letter B, should be used in infants as the muscle tends to be thickest in this area.