Nokea
When a nurse assesses a client's IV catheter insertion site and notes a hematoma, which of the following actions should the nurse take? (Select all that apply.)
- A. Stop the infusion.
- B. Apply alcohol to the insertion site.
- C. Apply warm compresses to the insertion site.
- D. Elevate the client's arm.
Correct Answer: C
Rationale: When a nurse detects a hematoma at the IV catheter insertion site, applying warm compresses is beneficial as it can promote healing by enhancing circulation and reducing swelling. Elevating the client's arm helps in reducing edema, which can relieve pressure, pain, and further bleeding in the hematoma area. Stopping the infusion may be necessary in certain situations, but it is not a standard action for all hematoma cases. Applying alcohol to the insertion site is discouraged as it can cause irritation and may not aid in resolving the hematoma.
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To which pharmacologic classification does the drug propranolol belong?
- A. Beta Blockers
- B. Cholinergics
- C. Immune globulins
- D. Barbiturates
Correct Answer: A
Rationale: Propranolol belongs to the pharmacologic classification of Beta Blockers. Beta blockers work by blocking the action of adrenaline and other stress hormones on beta-adrenergic receptors. They are commonly used to manage conditions like high blood pressure, angina, and arrhythmias. Choice B, Cholinergics, is incorrect because cholinergics work by stimulating the parasympathetic nervous system, unlike beta blockers that block adrenergic receptors. Choice C, Immune globulins, is incorrect as it refers to antibodies used to boost the immune system, not the mechanism of action of propranolol. Choice D, Barbiturates, is incorrect as barbiturates are a different class of drugs that act as central nervous system depressants, primarily used as sedatives and anesthetics.
Which of the following most accurately describes the antibacterial mechanism of penicillin:
- A. inhibits DNA synthesis
- B. inhibits the terminal step in peptidoglycan synthesis
- C. Inhibits protein synthesis in growing bacterial cells
- D. disrupts the integrity of the cell membrane
Correct Answer: B
Rationale: Penicillin is a type of antibiotic that works by inhibiting bacterial cell wall synthesis. Peptidoglycan is a critical component of the bacterial cell wall, providing structural support and preventing the cell from bursting. Penicillin specifically targets the final step in peptidoglycan synthesis, known as cross-linking, by binding to and inhibiting the enzyme transpeptidase. Without proper cross-linking of peptidoglycan, the bacterial cell wall becomes weak and compromised, leading to cell lysis and bacterial death. This mechanism makes penicillin highly effective in combating bacterial infections.
The nurse is caring for a client receiving tamoxifen (Nolvadex) for breast cancer. Which side effect should the nurse monitor for?
- A. Hot flashes
- B. Hair loss
- C. Nausea
- D. Diarrhea
Correct Answer: A
Rationale: Tamoxifen, an estrogen receptor modulator, treats breast cancer but blocks estrogen in some tissues, causing hot flashes , a common menopausal-like effect. Monitoring this ensures client comfort and adherence, as it's frequent and distressing. Hair loss is more chemotherapy-related, not tamoxifen. Nausea and diarrhea occur less often and are less specific. Hot flashes align with tamoxifen's anti-estrogenic action, a key consideration in breast cancer management where long-term use is common. This focus aids in symptom management, distinguishing it from cytotoxic effects, making A the priority side effect to monitor.
A client has a new prescription for Hydralazine. Which of the following side effects should the nurse instruct the client to monitor for and report?
- A. Orthostatic hypotension
- B. Increased heart rate
- C. Dark-colored urine
- D. Persistent cough
Correct Answer: B
Rationale: Corrected Rationale: Hydralazine, a vasodilator, can cause reflex tachycardia, leading to an increased heart rate. This side effect should be reported to the healthcare provider to ensure appropriate management and monitoring of the client's condition. Choice A (Orthostatic hypotension) is incorrect as Hydralazine is more likely to cause reflex tachycardia than orthostatic hypotension. Choice C (Dark-colored urine) and Choice D (Persistent cough) are unrelated to the common side effects of Hydralazine and should not be the focus of monitoring for this medication.
The adolescent is supposed to go to the school nurse at 12:00 to receive his medication for attention-deficit hyperactivity disorder (ADHD). He often does not go for the medication. What best describes the nurse's understanding of this situation?
- A. The adolescent is embarrassed in front of his peers
- B. The adolescent does not understand the need for the medication
- C. The adolescent forgets that he is supposed to take the medication
- D. The adolescent has made a conscious decision not to take the medication
Correct Answer: A
Rationale: Adolescents prioritize peer image-skipping ADHD meds (e.g., Ritalin) at school likely stems from embarrassment, a developmental trait. Lack of understanding or forgetting is possible but less likely with routine. Conscious refusal needs evidence (e.g., verbal rejection). Embarrassment fits social sensitivity, guiding intervention.