Nokea
A nurse is preparing to administer heparin subcutaneously to a client. Which of the following actions should the nurse plan to take?
- A. Administer the medication outside the 5 cm (2 in) radius of the umbilicus.
- B. Aspirate for blood return before injecting.
- C. Rub vigorously after the injection to promote absorption.
- D. Place a pressure dressing on the injection site to prevent bleeding.
Correct Answer: A
Rationale: The correct answer is A: Administer the medication outside the 5 cm (2 in) radius of the umbilicus. This is because injecting heparin near the umbilicus can lead to bruising or hematoma formation. Subcutaneous injections are generally given in the fatty tissue of the abdomen, but it is important to avoid the area around the umbilicus to prevent discomfort and complications. Aspiration for blood return (B) is not necessary for subcutaneous injections as they are not typically administered into a blood vessel. Rubbing vigorously after the injection (C) is not recommended as it can cause tissue damage. Placing a pressure dressing on the injection site (D) is also unnecessary for subcutaneous injections.
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A nurse is teaching a client about cyclobenzaprinWhich of the following client statements should indicate to the nurse that the teaching is effective?
- A. I will have increased saliva production.
- B. I will continue taking the medication until the rash disappears.
- C. I will taper off the medication before discontinuing it.
- D. I will report any urinary incontinence.
Correct Answer: C
Rationale: The correct answer is C: "I will taper off the medication before discontinuing it." This indicates effective teaching because cyclobenzaprine should not be abruptly stopped to prevent withdrawal symptoms. Tapering off gradually helps the body adjust. Saliva production (A) is not a typical side effect. Continuing until rash disappears (B) is incorrect as it may not be related to the medication. Reporting urinary incontinence (D) is important but not related to proper medication use.
A nurse is assessing a client after administering a second dose of cefazolin IV. The nurse notes the client has anxiety, hypotension. and dyspneWhich of the following medications should the nurse administer first?
- A. Diphenhydramine
- B. Albuterol inhaler
- C. Epinephrine
- D. Prednisone
Correct Answer: C
Rationale: The correct answer is C: Epinephrine. Epinephrine is the first-line treatment for anaphylaxis, which can present with symptoms such as anxiety, hypotension, and dyspnea following administration of a medication like cefazolin. Epinephrine acts quickly to reverse the severe allergic reaction by constricting blood vessels, increasing blood pressure, and opening up the airways to improve breathing. Diphenhydramine (A) is an antihistamine that can be used as an adjunct therapy but is not the first choice in an acute anaphylactic reaction. Albuterol inhaler (B) is used for bronchodilation in asthma, not for managing anaphylaxis. Prednisone (D) is a corticosteroid that may be used later in the treatment process to prevent a late-phase reaction but is not the initial treatment for anaphylaxis.
Complete the following sentence by using the lists of options. Upon analyzing the assessment findings, the nurse identifies that the client is at risk for _______ due to _______.
- A. concurrent medication use
- B. recent illness
- C. activity level
Correct Answer: A
Rationale: The correct answer is A: concurrent medication use. This is because identifying a client at risk for a condition due to concurrent medication use is crucial in nursing assessment. Medications can interact with each other, leading to adverse effects or reduced efficacy. Recent illness (B) and activity level (C) are important factors but do not directly relate to the risk due to medication use. The other choices (D, E, F, G) are irrelevant and do not address the potential risks associated with medication interactions. Thus, A is the most appropriate choice for identifying a client's risk based on assessment findings related to medication use.
For which of the following client outcomes should the nurse administer chlordiazepoxide to a client experiencing acute alcohol withdrawal?
- A. Minimize diaphoresis
- B. Maintain abstinence
- C. Lessen craving
- D. Prevent delirium tremens
Correct Answer: D
Rationale: The correct answer is D: Prevent delirium tremens. Chlordiazepoxide is a benzodiazepine used to manage acute alcohol withdrawal symptoms, including preventing delirium tremens, a severe and potentially life-threatening complication. It helps to stabilize the client's central nervous system by reducing the risk of seizures and severe agitation associated with delirium tremens. Choices A, B, and C are incorrect as chlordiazepoxide's primary role in alcohol withdrawal is not to minimize diaphoresis, maintain abstinence, or lessen craving, but rather to manage the more serious symptoms of withdrawal like delirium tremens.
A nurse is assessing a client 1 hr after administering morphine for pain. The nurse should identify which of the following findings as the best indication that the morphine has been effective?
- A. The client's vital signs are within normal limits.
- B. The client has not requested additional medication.
- C. The client is resting comfortably with eyes closed.
- D. The client rates pain as 3 on a scale from 0 to 10.
Correct Answer: D
Rationale: Correct Answer: D. The client rates pain as 3 on a scale from 0 to 10.
Rationale: Pain assessment is subjective. The client's self-report of pain is the most reliable indicator of pain relief efficacy. A pain rating of 3 indicates that the pain has decreased from the initial level, suggesting that the morphine has been effective in managing the pain.
Summary of Other Choices:
A: The client's vital signs being within normal limits may not directly correlate with pain relief. Vital signs can be influenced by various factors other than pain relief.
B: The client not requesting additional medication does not necessarily indicate effective pain management as some individuals may hesitate to ask for more medication.
C: The client resting comfortably with eyes closed may indicate relaxation but does not specifically confirm pain relief.
E, F, G: No additional choices provided.