Nokea
The nurse is preparing to administer a tuberculin skin test to a client. The nurse determines that which area is to be used for injection of the medication?
- A. Dorsal aspect of the upper arm near a mole
- B. Inner aspect of the forearm that is close to a burn scar
- C. Inner aspect of the forearm that is not heavily pigmented
- D. Dorsal aspect of the upper arm that has a small amount of hair
Correct Answer: C
Rationale: Intradermal injections are most commonly given in the inner surface of the forearm. Other sites include the dorsal area of the upper arm or the upper back beneath the scapulae. The nurse finds an area that is not heavily pigmented and is clear of hairy areas or lesions that could interfere with reading the results.
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Which nursing question would elicit the most thorough assessment data regarding the client's recent sleeping patterns?
- A. Are you sleeping well at home?
- B. Did you get much sleep last night?
- C. May we talk about how you've been sleeping?
- D. Do you think you get enough sleep on a nightly basis?
Correct Answer: C
Rationale: Option 3 is a question and provides the client the opportunity to express thoughts and feelings. The remaining options could lead to a one-word answer that would not provide thorough assessment data. Additionally, one night of sleep may not tell the nurse how the pattern has been over time.
A client experiencing trigeminal neuralgia (tic douloureux) asks the nurse for a snack and something to drink. Which is the best selection the nurse should provide for the client?
- A. Hot cocoa with honey and toast
- B. Vanilla pudding and lukewarm milk
- C. Hot herbal tea with graham crackers
- D. Iced coffee and peanut butter and crackers
Correct Answer: B
Rationale: Because mild tactile stimulation of the face of clients with trigeminal neuralgia can trigger pain, the client needs to eat or drink lukewarm, nutritious foods that are soft and easy to chew. Extremes of temperature will cause trigeminal pain.
The nurse is assessing a client who is being treated with a beta-adrenergic blocker. Which assessment findings would indicate that the client may be experiencing dose-related side effects of the medication? Select all that apply.
- A. Dizziness
- B. Bradycardia
- C. Chest pain
- D. Reflex tachycardia
- E. Sexual dysfunction
- F. Cardiac dysrhythmias
Correct Answer: A,B,E
Rationale: Beta-adrenergic blockers, commonly called beta blockers, are useful in treating cardiac dysrhythmias, mild hypertension, mild tachycardia, and angina pectoris. Side effects commonly associated with beta blockers are usually dose related and include dizziness (hypotensive effect), bradycardia, hypotension, and sexual dysfunction (impotence). Options 3, 4, and 6 are reasons for prescribing a beta blocker; however, these are general side effects of alpha-adrenergic blockers.
The nurse is assessing a client diagnosed with pleurisy 48 hours ago. When auscultating the chest the nurse is unable to detect the pleural friction rub, which was auscultated on admission. This change in the client's condition confirms which event has occurred?
- A. The prescribed medication therapy has been effective.
- B. The client has been taking deep breaths as instructed.
- C. The effects of the inflammatory reaction at the site decreased.
- D. There is now an accumulation of pleural fluid in the inflamed area.
Correct Answer: D
Rationale: Pleurisy is the inflammation of the visceral and parietal membranes. These membranes rub together during respiration and cause pain. Pleural friction rub is auscultated early in the course of pleurisy, before pleural fluid accumulates. Once fluid accumulates in the inflamed area, there is less friction between the visceral and parietal lung surfaces, and the pleural friction rub disappears. Options 1, 2, and 3 are incorrect interpretations.
The nurse has a prescription to administer amphotericin B intravenously to the client diagnosed with histoplasmosis. Which should the nurse specifically plan to implement during administration of the medication to minimize the client's risk for injury? Select all that apply.
- A. Monitor for hyperthermia.
- B. Monitor for an excessive urine output.
- C. Administer a concurrent fluid challenge.
- D. Assess the intravenous (IV) infusion site.
- E. Assess the chest and back for a red, itchy rash.
- F. Monitor the client's orientation to time, place, and person.
Correct Answer: A,D
Rationale: Amphotericin B is an antifungal medication and is a toxic medication, which can produce symptoms during administration such as chills, fever (hyperthermia), headache, vomiting, and impaired renal function (decreased urine output). The medication is also very irritating to the IV site, commonly causing thrombophlebitis. The nurse administering this medication monitors for these complications. Administering a concurrent fluid challenge is not necessary. A rash or disorientation is not specific to this medication.