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The nurse is monitoring a client receiving a thrombolytic agent, alteplase (Activase tissue plasminogen activator), for treatment of a myocardial infarction. What outcome indicates the client is receiving adequate therapy within the first hours of treatment?
- A. Absence of a dysrhythmia (or arrhythmia)
- B. Blood pressure reduction
- C. Cardiac enzymes are within normal limits
- D. Return of ST segment to baseline on ECG
Correct Answer: D
Rationale: Return of ST segment to baseline on ECG. Improved perfusion should result from this medication, along with the reduction of ST segment elevation.
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A 6-year-old child is seen in the emergency room after stepping on a rusty nail. He has received no immunizations. What should the nurse expect to give him immediately to prevent a tetanus infection?
- A. Tetanus toxoid
- B. DTaP
- C. Immune serum globulin
- D. Penicillin
Correct Answer: C
Rationale: Immune serum globulin provides immediate passive immunity against tetanus in an unimmunized child.
The nurse is administering an intramuscular (IM) injection to a client. When the nurse aspirates, there is a blood return. What is the most appropriate action for the nurse to take?
- A. Continue to administer the medication
- B. Withdraw the needle and administer in another site
- C. Withdraw the needle, discard the medication, and start over
- D. Change the needle before administering the medication in another site
Correct Answer: C
Rationale: The nurse should not inject medication that has blood in it. Blood may interact with the medication and cause an adverse response.
The client is complaining of low-back pain and is prescribed the muscle relaxant carisoprodol (Soma). Which teaching intervention has priority?
- A. Explain this medication causes GI distress.
- B. Discuss the need to taper off this medication.
- C. Warn this medication will cause drowsiness.
- D. Instruct the client to limit alcohol intake.
Correct Answer: C
Rationale: Carisoprodol causes drowsiness, a safety risk (e.g., falls, driving); warning is the priority. GI distress, tapering, or alcohol are secondary.
The client on bedrest is receiving enoxaparin (Lovenox), a low molecular weight heparin. Which anatomical site is recommended for administering this medication?
- A. The abdominal wall one (1) inch away from the umbilicus.
- B. The vastus lateralis with a 23-gauge needle.
- C. In the deltoid area subcutaneously.
- D. In the anterolateral abdomen.
Correct Answer: D
Rationale: Enoxaparin is injected subcutaneously in the anterolateral abdomen for optimal absorption and minimal bruising, per manufacturer guidelines.
A client with atrial fibrillation is receiving digoxin (Lanoxin). Which of these assessments is most important for the nurse to perform?
- A. Monitor blood pressure every 4 hours
- B. Measure apical pulse prior to administration
- C. Maintain accurate intake and output records
- D. Record an EKG strip after administration
Correct Answer: B
Rationale: Measure apical pulse prior to administration. Digitoxin decreases conduction velocity through the AV node and prolongs the refractory period. If the apical heart rate is less than 60 beats/minute, withhold the drug. The apical pulse should be taken with a stethoscope so that there will be no mistake about what the heart rate actually is.