Nokea
The employee health nurse is discussing hepatitis B vaccines with new employees. Which statement best describes the proper administration of the hepatitis B vaccine?
- A. The vaccine must be administered once a year.
- B. Two (2) mL of vaccine should be given in each hip.
- C. The vaccine is given in three (3) doses over a six (6)-month time period.
- D. The vaccine is administered intradermally into the deltoid muscle.
Correct Answer: C
Rationale: Hepatitis B vaccine is given in three IM doses (0, 1, 6 months), per CDC guidelines. Annual dosing, split doses, or intradermal routes are incorrect.
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When administering eye drops, the nurse should administer the drops into which location?
- A. The pupil
- B. The conjunctival sac
- C. The inner canthus
- D. The cornea
Correct Answer: B
Rationale: Eye drops are administered into the conjunctival sac to ensure proper distribution and minimize corneal irritation.
A client has been receiving dexamethasone (Decadron) for control of cerebral edema. Which of the following assessments would indicate that the treatment is effective?
- A. A positive Babinski's reflex
- B. Increased response to motor stimuli
- C. A widening pulse pressure
- D. Temperature of 37 degrees Celsius
Correct Answer: B
Rationale: Decadron is a corticosteroid that acts on the cell membrane to decrease inflammatory responses as well as stabilize the blood-brain barrier. Once Decadron reaches a therapeutic level, there should be a decrease in symptomatology with improvement in motor skills.
A client is receiving erythromycin 500 mg IV every 6 hours to treat a pneumonia. Which of the following is the most common side effect of the medication?
- A. Blurred vision
- B. Nausea and vomiting
- C. Severe headache
- D. Insomnia
Correct Answer: B
Rationale: Nausea and vomiting. Nausea is a common side-effect of erythromycin in both oral and intravenous forms.
The female nurse realizes she did not administer a medication on time to the client diagnosed with a myocardial infarction. Which action should the nurse implement?
- A. Administer the medication and take no further action.
- B. Notify the director of nurses of the medication error.
- C. Complete a medication error report form.
- D. Report the error to the Peer Review Committee.
Correct Answer: C
Rationale: A medication error requires completing an error report per facility policy to ensure tracking and quality improvement, especially for MI patients.
The client diagnosed with epilepsy is being discharged from the hospital with a prescription for phenytoin (Dilantin) by mouth. Which discharge instructions should the nurse discuss with the client?
- A. The client should purchase a self-monitoring Dilantin machine.
- B. The client should see the dentist at least every six (6) months.
- C. The client should never drive when taking this medication.
- D. The client should drink no more than one (1) glass of wine a day.
Correct Answer: B
Rationale: Phenytoin causes gingival hyperplasia; regular dental visits prevent complications. No self-monitoring machines exist, driving bans are not absolute, and alcohol limits are secondary.