Nokea
The nurse is administering an otic drop to the 45-year-old client. Which procedure should the nurse implement when administering the drops?
- A. Place the drops when pulling the ear down and back.
- B. Place the drops when pulling the ear up and back.
- C. Place the drops in the lower conjunctival sac.
- D. Place the drops in the inner canthus and apply pressure.
Correct Answer: B
Rationale: For adults, pulling the ear up and back straightens the ear canal for otic drops. Down/back is for children, others are for ophthalmic drops.
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Which of the following persons would be least likely to receive tetracycline?
- A. An adolescent with acne
- B. A woman with chlamydia who is seven months pregnant
- C. A 10-year-old child with Rocky Mountain spotted fever
- D. A 32-year-old man with walking pneumonia
Correct Answer: B
Rationale: Tetracycline can damage developing teeth in fetuses and children under 8, making the pregnant woman least likely to receive it.
You are caring for a client with deep vein thrombosis who is on Heparin IV. The latest APTT is 50 seconds. If the laboratory normal range is 16-24 seconds, you would anticipate
- A. maintaining the current heparin dose
- B. increasing the heparin as it does not appear therapeutic
- C. giving protamine sulfate as an antidote
- D. repeating the blood test 1 hour after giving heparin
Correct Answer: A
Rationale: maintaining the current heparin dose. The range for a therapeutic APTT is 1.5-2 times the control. Therefore the client is receiving a therapeutic dose of Heparin.
The nurse is administering digoxin, a cardiac glycoside, to the client with congestive heart failure. Which interventions should the nurse implement? Select all that apply.
- A. Check the apical heart rate for one (1) full minute.
- B. Monitor the client's serum sodium level.
- C. Teach the client how to take his or her radial pulse.
- D. Evaluate the client's serum digoxin level.
- E. Assess the client for buffalo hump and moon face.
Correct Answer: A,C,D
Rationale: Checking apical HR prevents bradycardia, teaching pulse empowers monitoring, and digoxin levels ensure therapeutic range. Sodium or Cushingoid features are irrelevant.
The clinic nurse is teaching an adult male who has AIDS. He is receiving zidovudine. Which statement he makes indicates that he understands the medication regimen?
- A. If I get a sore throat and it is hard to swallow my capsules, I can empty the capsule into applesauce.
- B. I am hopeful that this drug will get rid of this awful disease.
- C. I understand I might need a transfusion.
- D. I should take acetaminophen (Tylenol), not aspirin, if I get a fever.
Correct Answer: D
Rationale: Zidovudine can cause bone marrow suppression; acetaminophen is safer than aspirin, which increases bleeding risk.
The nurse is caring for a client who is receiving procainamide (Pronestyl) intravenously. It is important for the nurse to monitor which of the following parameters?
- A. Hourly urinary output
- B. Serum potassium levels
- C. Continuous EKG readings
- D. Neurological signs
Correct Answer: C
Rationale: Continuous EKG readings. Procainamide (Pronestyl) is used to suppress cardiac arrhythmias. When administered intravenously, it must be accompanied by continuous cardiac monitoring by ECG.