Nokea
The HCP has ordered an intramuscular antibiotic. After reconstituting the medication, the clinic nurse must administer 4.8 mL of the medication. Which action should the nurse implement first when administering this medication?
- A. Inform the HCP the amount of medication is too large.
- B. Administer the medication in the gluteal muscle.
- C. Discard the medication in the sharps container.
- D. Divide the medication and give 2.4 mL in each hip.
Correct Answer: D
Rationale: IM injections >3 mL should be divided; 2.4 mL in each hip (gluteal) ensures safe absorption. Notifying HCP, single-site injection, or discarding are incorrect.
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A 67-year-old client is to be discharged from the hospital. The client is taking digoxin and furosemide daily. Which instruction is most essential for the nurse to give this client?
- A. Take your medicine early in the day.
- B. Be sure to drink orange juice and eat bananas or melons every day.
- C. Avoid foods that are high in sodium.
- D. Drink plenty of milk.
Correct Answer: B
Rationale: Furosemide causes potassium loss; orange juice, bananas, and melons are potassium-rich, preventing hypokalemia.
The nurse is administering carbidopa/levodopa (Sinemet) to the client. Which assessment should the nurse perform to determine if the medication is effective?
- A. Assess the client's muscle strength.
- B. Assess for cogwheel movements.
- C. Assess the carbidopa serum level.
- D. Assess the client's blood pressure.
Correct Answer: B
Rationale: Carbidopa/levodopa reduces Parkinson’s symptoms like cogwheel rigidity; decreased cogwheel movements indicate effectiveness. Strength, levels, or BP are less specific.
The client is receiving the angiotensin-converting enzyme (ACE) inhibitor enalapril (Vasotec). When would the nurse question administering this medication?
- A. The client is not receiving potassium supplements.
- B. The client complains of a persistent irritating cough.
- C. The blood pressure for two (2) consecutive readings is 110/70.
- D. The client's urinary output is 400 mL for the last eight (8) hours.
Correct Answer: B
Rationale: A persistent cough is a common ACE inhibitor side effect, warranting discontinuation or HCP evaluation. Potassium, BP, or urine output are less critical.
The client is complaining of incisional pain. Which intervention should the nurse implement first?
- A. Administer the pain medication STAT.
- B. Determine when the last pain medication was given.
- C. Assess the client's pulse and blood pressure.
- D. Teach the client distraction techniques to address pain.
Correct Answer: B
Rationale: Determining the last dose ensures safe timing and avoids overdose, the first step in pain management per nursing process.
A toddler who has swallowed several adult aspirin is admitted to the emergency room. When admitted, the child is breathing but is difficult to arouse. What is the immediate priority of care?
- A. Administration of syrup of ipecac
- B. Cardiopulmonary resuscitation
- C. Ventilatory support
- D. Gastric lavage
Correct Answer: D
Rationale: Gastric lavage is the priority to remove aspirin from the stomach, preventing further absorption, given the child is breathing but unresponsive.