Nokea
The nurse is preparing to administer a medication from a multi-dose bottle. The label is torn and soiled, but the name of the medication is still readable. What is the nurse's priority action?
- A. Administer the medication if the name of the drug can be clearly read.
- B. Discard the entire bottle and contents and obtain a new bottle.
- C. Ask another nurse to verify the contents of the bottle.
- D. Find the drug information and make a new label for the bottle.
Correct Answer: B
Rationale: The correct answer is B: Discard the entire bottle and contents and obtain a new bottle. The nurse's priority is patient safety. A torn and soiled label increases the risk of administering the wrong medication, dosage, or route. Discarding the bottle ensures that the correct medication is given, preventing potential harm to the patient. Administering the medication with a damaged label poses a significant risk of medication error. Asking another nurse to verify or making a new label does not eliminate the risk associated with using a compromised bottle. Finding drug information for a new label may introduce inaccuracies. Prioritizing patient safety by obtaining a new bottle is the best course of action in this situation.
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Ask the nurse to explain the type of angina he is experiencing. The nurse explains the pain is due to the imbalance of myocardial supply.
- A. Unstable.
- B. Ischemic.
- C. Stable angina.
- D. Prinzmetal.
Correct Answer: C
Rationale: The correct answer is C: Stable angina. This type of angina occurs due to a predictable pattern of exertional activities causing chest pain. The imbalance in myocardial supply and demand is typically relieved with rest or medication. Unstable angina (A) is characterized by unpredictable chest pain at rest or with minimal exertion, indicating a more severe condition. Ischemic (B) refers to inadequate blood flow to the heart muscle, which can lead to angina. Prinzmetal angina (D) is caused by coronary artery spasm rather than exertion, making it less likely in this scenario.
How do antiplatelet medications work?
- A. Stimulate the plasmin system.
- B. Alter the formation of the platelet plug.
- C. Initiate the clotting cascade.
- D. Interfere with the clotting cascade.
Correct Answer: B
Rationale: The correct answer is B: Alter the formation of the platelet plug. Antiplatelet medications work by inhibiting platelet aggregation, preventing the formation of blood clots. They do not stimulate the plasmin system (A), initiate the clotting cascade (C), or interfere with the clotting cascade (D). By blocking platelet aggregation, these medications help reduce the risk of thrombosis and cardiovascular events.
A patient is diagnosed as having elevated cholesterol level. The nurse is aware that plaque on the inner lumen of arteries begins as what?
- A. Platelets and fibrin.
- B. Fatty streaks.
- C. White blood cells (WBC).
- D. Foam cells.
Correct Answer: B
Rationale: The correct answer is B: Fatty streaks. Fatty streaks are the earliest visible signs of atherosclerosis and are primarily composed of lipid-laden macrophages within the arterial wall. Platelets and fibrin (A) are involved in clot formation, not the initial stages of plaque formation. White blood cells (C) and foam cells (D) are involved in the later stages of atherosclerosis. The other choices are irrelevant to the initial development of plaque.
A geriatric patient received a narcotic analgesic before leaving the post-anesthesia care unit to return to the regular unit. What is the priority nursing action for the nurse receiving the patient on the regular unit?
- A. Administer a non-steroidal anti-inflammatory drug.
- B. Put side rails up and place bed in the lowest position.
- C. Encourage fluids.
- D. Create a restful dark environment.
Correct Answer: B
Rationale: The correct answer is B: Put side rails up and place bed in the lowest position. This is the priority nursing action as the geriatric patient who received a narcotic analgesic may experience drowsiness or confusion, increasing the risk of falls. By putting up the side rails and lowering the bed, the nurse is ensuring the patient's safety and preventing falls. Administering a non-steroidal anti-inflammatory drug (choice A) is not the priority as the patient's safety should be addressed first. Encouraging fluids (choice C) and creating a restful dark environment (choice D) are important but not as crucial as ensuring the patient's immediate safety.
A patient exhibits ptosis of both eyes and the provider orders edrophonium (Tensilon). The nurse notes immediate improvement of the ptosis. The nurse understands that this patient most likely has which disorder?
- A. Myasthenia gravis.
- B. Cerebral palsy.
- C. Multiple sclerosis.
- D. Muscle spasm.
Correct Answer: A
Rationale: The correct answer is A: Myasthenia gravis. Edrophonium is a reversible acetylcholinesterase inhibitor that improves muscle strength in patients with myasthenia gravis due to its ability to increase acetylcholine levels at the neuromuscular junction. The immediate improvement of ptosis after administration of edrophonium suggests a diagnosis of myasthenia gravis, a disorder characterized by muscle weakness and fatigability. Cerebral palsy (B) is a non-progressive neurological disorder not typically associated with ptosis and not responsive to edrophonium. Multiple sclerosis (C) is an autoimmune demyelinating disorder that does not typically present with ptosis. Muscle spasm (D) does not explain the ptosis and would not improve with edrophonium.