Nokea
The nurse is preparing to administer the initial dose of an antibiotic in the emergency department. Which interventions should the nurse implement? Select all that apply.
- A. Assess for drug allergies.
- B. Collect needed specimens for culture.
- C. Check the client's armband.
- D. Ask the client his or her birthday.
- E. Draw peak and trough levels.
Correct Answer: A,B,C
Rationale: Allergy assessment prevents reactions, cultures guide therapy, and armband ensures identity. Birthday is redundant, and peak/trough levels are post-administration.
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The client with arthritis is self-medicating with aspirin, a nonsteroidal anti-inflammatory medication. Which complication should the nurse discuss with the client?
- A. Tinnitus.
- B. Diarrhea.
- C. Tetany.
- D. Paresthesia.
Correct Answer: A
Rationale: High-dose aspirin can cause tinnitus, an early sign of salicylate toxicity, requiring education. Diarrhea, tetany, or paresthesia are less common.
The provider has ordered transdermal nitroglycerin patches for a client. Which of these instructions should be included when teaching a client about how to use the patches?
- A. Remove the patch when swimming or bathing
- B. Apply the patch to any non-hairy area of the body
- C. Apply a second patch with chest pain
- D. Remove the patch if ankle edema occurs
Correct Answer: B
Rationale: Apply the patch to any non-hairy area of the body. The patch application sites should be rotated.
The client is diagnosed with tuberculosis and prescribed rifampin and isoniazid (INH), both antituberculosis medications. Which instruction is most important for the public health nurse to discuss with the client?
- A. The client will have to take the medications for nine (9) to 12 months.
- B. The client will have to stay in isolation as long as he or she is taking medications.
- C. Explain the client cannot eat any type of pork products while taking the medication.
- D. The urine may turn turquoise in color, but this is an expected occurrence and harmless.
Correct Answer: A
Rationale: TB treatment requires 9–12 months for cure, ensuring adherence is critical to prevent resistance, a public health priority. Isolation, pork, or urine color are incorrect or less urgent.
The client is receiving a continuous heparin drip, 20,000 units/500 mL D5W, at 23 mL/min. How many units of heparin is the client receiving an hour?
Correct Answer: 55200
Rationale: Concentration: 20,000 units / 500 mL = 40 units/mL. Rate: 23 mL/min x 60 min/hr = 1,380 mL/hr. Dose: 1,380 mL/hr x 40 units/mL = 55,200 units/hr.
When administering eye drops, the nurse should administer the drops into which location?
- A. The pupil
- B. The conjunctival sac
- C. The inner canthus
- D. The cornea
Correct Answer: B
Rationale: Eye drops are administered into the conjunctival sac to ensure proper distribution and minimize corneal irritation.