Nokea
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.
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A toddler who has swallowed several adult aspirin is admitted to the emergency room. When admitted, the child is breathing but is difficult to arouse. What is the immediate priority of care?
- A. Administration of syrup of ipecac
- B. Cardiopulmonary resuscitation
- C. Ventilatory support
- D. Gastric lavage
Correct Answer: D
Rationale: Gastric lavage is the priority to remove aspirin from the stomach, preventing further absorption, given the child is breathing but unresponsive.
The HCP has ordered an intramuscular antibiotic. After reconstituting the medication, the clinic nurse must administer 4.8 mL of the medication. Which action should the nurse implement first when administering this medication?
- A. Inform the HCP the amount of medication is too large.
- B. Administer the medication in the gluteal muscle.
- C. Discard the medication in the sharps container.
- D. Divide the medication and give 2.4 mL in each hip.
Correct Answer: D
Rationale: IM injections >3 mL should be divided; 2.4 mL in each hip (gluteal) ensures safe absorption. Notifying HCP, single-site injection, or discarding are incorrect.
A client has bilateral knee pain from osteoarthritis. In addition to taking the prescribed non-steroidal anti-inflammatory drug (NSAID), the nurse should instruct the client to
- A. start a regular exercise program
- B. rest the knees as much as possible to decrease inflammation
- C. avoid foods high in citric acid
- D. keep the legs elevated when sitting
Correct Answer: A
Rationale: start a regular exercise program. A regular exercise program is beneficial in treating osteoarthritis. It can restore self-esteem and improve physical functioning.
A client has been receiving dexamethasone (Decadron) for control of cerebral edema. Which of the following assessments would indicate that the treatment is effective?
- A. A positive Babinski's reflex
- B. Increased response to motor stimuli
- C. A widening pulse pressure
- D. Temperature of 37 degrees Celsius
Correct Answer: B
Rationale: Decadron is a corticosteroid that acts on the cell membrane to decrease inflammatory responses as well as stabilize the blood-brain barrier. Once Decadron reaches a therapeutic level, there should be a decrease in symptomatology with improvement in motor skills.
The female nurse realizes she did not administer a medication on time to the client diagnosed with a myocardial infarction. Which action should the nurse implement?
- A. Administer the medication and take no further action.
- B. Notify the director of nurses of the medication error.
- C. Complete a medication error report form.
- D. Report the error to the Peer Review Committee.
Correct Answer: C
Rationale: A medication error requires completing an error report per facility policy to ensure tracking and quality improvement, especially for MI patients.