Nokea
The nurse is preparing to administer phenytoin (Dilantin), 100 mg intravenous push, to the client with a head injury who has an IV of D5W at 50 mL/hr. Which intervention should the nurse implement?
- A. Flush the IV tubing before and after with normal saline.
- B. Administer the medication if the Dilantin level is 22 mcg/mL.
- C. Push the Dilantin intravenously slowly over five (5) minutes.
- D. Expect the intravenous tubing to turn cloudy when infusing medication.
Correct Answer: A
Rationale: Phenytoin is incompatible with D5W; saline flush prevents precipitation. Level of 22 mcg/mL is toxic, slow push is correct but not primary, and cloudiness is avoidable.
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The nurse is to administer a subcutaneous (SC) injection. Which technique is correct?
- A. Pull the skin taut. Insert a 21-gauge needle at a 90-degree angle.
- B. Pinch the skin. Insert a 25-gauge needle at a 45-degree angle.
- C. Stretch the skin taut. Insert a 27-gauge needle at a 10-degree angle.
- D. Pinch the skin. Insert a 21-gauge needle at a 60-degree angle.
Correct Answer: B
Rationale: The skin should be pinched, and a 25-gauge needle should be inserted at a 45-degree angle. Answer 1 describes an IM injection. Answer 3 describes an intradermal injection.
When providing discharge teaching to a client with asthma, the nurse will warn against the use of which of the following over-the-counter medications?
- A. Cortisone ointments for skin rashes
- B. Aspirin products for pain relief
- C. Cough medications containing guaifenesin
- D. Histamine blockers for gastric distress
Correct Answer: B
Rationale: Aspirin products for pain relief. Aspirin is known to induce asthma attacks. Aspirin can also cause nasal polyps and rhinitis. Warn individuals with asthma about signs and symptoms resulting from complications due to aspirin ingestion.
You are caring for a hypertensive client with a new order for captopril (Capoten). Which information should the nurse include in client teaching?
- A. Avoid green leafy vegetables
- B. Restrict fluids to 1000 cc/day
- C. Avoid the use of salt substitutes
- D. Take the medication with meals
Correct Answer: C
Rationale: Avoid the use of salt substitutes. Captopril can cause an accumulation of potassium or hyperkalemia. Clients should avoid the use of salt substitutes, which are generally potassium-based.
A 60-year-old client has been hospitalized for deep vein thrombosis. The client is to be discharged on warfarin (Coumadin) 5 mg PO daily. Which statement that the client makes indicates the best understanding of the medication routine?
- A. I will take aspirin for my arthritis.
- B. I love to eat spinach salads.
- C. I will get a blood test next week.
- D. I made an appointment to have my teeth pulled.
Correct Answer: C
Rationale: Warfarin requires regular INR monitoring via blood tests to ensure therapeutic anticoagulation levels.
The client is showing ventricular ectopy, and the HCP orders amiodarone (Cordarone) intravenously. Which interventions should the nurse implement? Select all that apply.
- A. Monitor telemetry continuously.
- B. Assess the client's respiratory status.
- C. Evaluate the client's liver function studies.
- D. Confirm the original order with another nurse.
- E. Prepare to defibrillate the client at 200 joules.
Correct Answer: A,B,C
Rationale: Telemetry monitors dysrhythmias, respiratory status tracks amiodarone’s pulmonary toxicity risk, and liver studies monitor hepatotoxicity. Order confirmation is unnecessary, and defibrillation is unrelated.