Nokea
The nurse plans to evaluate the effectiveness of several drugs administered by different routes. Arrange the routes of administration from fastest to slowest rate of absorption. 1. Intravenous 2. Sublingual 3. Intramuscular 4. Subcutaneous
- A. 1,2,3,4
- B. 4,3,2,1
- C. 2,4,3,1
- D. 3,4,1,2
Correct Answer: A
Rationale: The correct order of routes of administration from fastest to slowest rate of absorption is 1. Intravenous, 2. Sublingual, 3. Intramuscular, 4. Subcutaneous. Intravenous administration provides the fastest absorption as the drug is directly injected into the bloodstream. Sublingual administration allows for rapid absorption through the mucous membranes under the tongue. Intramuscular administration has a slower absorption rate as the drug is injected into the muscle tissue. Subcutaneous administration is the slowest as the drug is injected into the fatty tissue under the skin, leading to a slower absorption compared to the other routes.
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The client with diabetes is being taught about the importance of foot care. Which statement by the client indicates a need for further teaching?
- A. ''I will inspect my feet daily for any cuts or blisters.''
- B. ''I will soak my feet in warm water every day.''
- C. ''I will wear shoes that fit properly to avoid injury.''
- D. ''I will avoid walking barefoot to protect my feet.''
Correct Answer: B
Rationale: Choice B is the correct answer because soaking feet daily can lead to skin breakdown, making it inappropriate for clients with diabetes. Inspecting feet daily for cuts or blisters (Choice A), wearing properly fitting shoes (Choice C), and avoiding walking barefoot (Choice D) are all appropriate measures to maintain foot health for clients with diabetes.
Prior to administering morphine sulfate (Morphine), the nurse takes the client's vital signs. Based on which finding should the nurse withhold administration of the medication until the charge nurse is notified?
- A. Temperature of 100.8°F
- B. A pulse rate of 150 beats per minute
- C. A respiratory rate of 10 breaths per minute
- D. A blood pressure of 180/110
Correct Answer: C
Rationale: The correct answer is C because a low respiratory rate is a critical concern when administering opioids like morphine, as they can suppress breathing. A high pulse rate (choice B) and high blood pressure (choice D) are not immediate contraindications for administering morphine. A slightly elevated temperature (choice A) may not necessarily require withholding morphine.
A client begins taking an antidepressant drug during the second day of hospitalization. Which assessment is most important for the nurse to include in this client's plan of care while the client is taking the antidepressant?
- A. Appetite
- B. Mood
- C. Withdrawal
- D. Energy level
Correct Answer: B
Rationale: Corrected Rationale: Monitoring the client's mood is essential when starting an antidepressant to assess for any changes or adverse effects related to the medication. Changes in mood can indicate the effectiveness of the antidepressant or potential side effects. Assessing appetite (Choice A) is important but not as crucial as monitoring mood in this context. Withdrawal symptoms (Choice C) are more relevant when discontinuing antidepressants rather than starting them. Energy level (Choice D) can be influenced by various factors and may not directly reflect the client's response to the antidepressant.
A client with a diagnosis of diabetes mellitus is experiencing symptoms of hypoglycemia. What is the nurse's priority intervention?
- A. Administer glucagon intramuscularly.
- B. Provide a complex carbohydrate snack.
- C. Administer 50% dextrose intravenously.
- D. Give 15 grams of a fast-acting carbohydrate.
Correct Answer: D
Rationale: The correct answer is to give 15 grams of a fast-acting carbohydrate as the priority intervention in a client experiencing hypoglycemia. This helps quickly raise the blood glucose level. Administering glucagon intramuscularly (Choice A) is typically reserved for severe hypoglycemia where the client is unable to take oral carbohydrates. Providing a complex carbohydrate snack (Choice B) is not the priority in an acute hypoglycemic episode where immediate action is needed. Administering 50% dextrose intravenously (Choice C) is more invasive and usually reserved for cases where the client is unable to take anything by mouth.
A client with a diagnosis of chronic heart failure is prescribed digoxin. What is the most important assessment before administering this medication?
- A. Check blood pressure
- B. Assess heart rate
- C. Monitor respiratory rate
- D. Measure oxygen saturation
Correct Answer: B
Rationale: The correct answer is to assess the heart rate before administering digoxin. Digoxin can lead to bradycardia, making it crucial to evaluate the heart rate to prevent potential complications. Checking blood pressure (Choice A) is important but not as critical as assessing the heart rate in this context. Monitoring respiratory rate (Choice C) and measuring oxygen saturation (Choice D) are not the most crucial assessments before administering digoxin, as the primary concern with this medication is its impact on heart rate.