Nokea
The nurse is preparing to administer a dose of enoxaparin (Lovenox) to a client with a pulmonary embolism. Which of the following actions by the nurse is correct?
- A. Administer the injection in the deltoid muscle.
- B. Massage the injection site after administration.
- C. Inject the medication into the abdomen, at least 2 inches from the umbilicus.
- D. Aspirate before injecting to check for blood return.
Correct Answer: C
Rationale: enoxaparin is administered subcutaneously in the abdomen, at least 2 inches from the umbilicus, without aspiration or massage
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The nurse administers a dose of acetaminophen to the wrong client. Which of the following actions is the most appropriate after notifying the physician?
- A. Notify her supervisor and complete an incident report.
- B. Ask the physician for an order of acetaminophen to cover the inadvertent administration.
- C. Take no further action because acetaminophen is relatively benign.
- D. Document in the client's record that an error in drug administration occurred.
Correct Answer: A
Rationale: Medication errors require notifying the supervisor and completing an incident report (A) to ensure proper follow-up and system improvements. Retroactively obtaining an order (B) is unethical, assuming acetaminophen is benign (C) is unsafe, and documenting the error in the client's record (D) is inappropriate.
A client in cardiac arrest is given 40 units of vasopressin (Pitressin) IV push. The nurse knows the desired action of this medication in a cardiac arrest is to
- A. raise blood pressure.
- B. stop cardiac arrhythmia.
- C. lower blood pressure.
- D. reset the electrical cardiac conduction system.
Correct Answer: A
Rationale: Vasopressin, used in cardiac arrest, is a vasopressor that raises blood pressure by vasoconstriction, improving perfusion during CPR.
The nurse is doing hourly rounds when he finds a 73-year-old female client unconscious on the floor next to the bed. An incident report must be filled out. What is the best statement for the nurse to write on the incident report?
- A. Client fell out of bed at some point between 0700 and 0800.'
- B. Client was found unresponsive on floor next to the bed.'
- C. Client likely slipped on the floor and hit her head.'
- D. Client attempted to ambulate without assistance and fell.'
Correct Answer: B
Rationale: The incident report should state objective findings: 'Client was found unresponsive on floor next to the bed.' Speculative statements (slipped, attempted to ambulate) are inappropriate.
The patient is prescribed metronidazole (Flagyl) for adjunct treatment for a duodenal ulcer. When teaching about this medication, the nurse would include:
- A. This medication should be taken only until you begin to feel better.'
- B. This medication should be taken on an empty stomach to increase absorption.'
- C. While taking this medication, you do not have to be concerned about being in the sun.'
- D. While taking this medication, alcoholic beverages and products containing alcohol should be avoided.'
Correct Answer: D
Rationale: Metronidazole can cause a disulfiram-like reaction with alcohol, so avoidance is critical.
The nurse is caring for a client with documented severe allergies to latex. Which item on the client's meal tray should the nurse remove?
- A. a banana
- B. a bowl of beef broth
- C. a vanilla pudding cup
- D. a cup of strawberries
Correct Answer: A
Rationale: Bananas can cause a cross-reaction in latex-allergic clients due to shared proteins (latex-fruit syndrome). Other items are safe.