Nokea
Nurses’ notes
Vital Signs
Medication Administration Record
Client reports tightness in the chest that radiates to the left arm. States pain as 7 on a scale of 0 to 10. Client is diaphoretic and short of breath.
Which of the following instructions should the nurse include when reinforcing teaching to the client about their medication? Select all that apply.
- A. Lie down with feet elevated if dizziness occurs while taking this medication.
- B. Apply the patch daily to a hairless area of the skin.
- C. The medication will be effective 30 to 45 min following application.
- D. Remove the patch 12 to 14 hr following application.
- E. Remove the patch if you experience a headache.
- F. Place the patch on the same area every day.
Correct Answer: A,B,D
Rationale: Correct answer: A, B, D
Rationale:
A: Instructing the client to lie down with feet elevated if dizziness occurs is important as it can prevent falls and injury.
B: Applying the patch to a hairless area of the skin ensures proper drug absorption and effectiveness.
D: Removing the patch after 12 to 14 hours prevents skin irritation and ensures the medication is not being overexposed.
Incorrect answer explanations:
C: The time frame given for medication effectiveness is inaccurate and may lead to confusion.
E: Removing the patch if experiencing a headache is not a standard instruction and may interfere with the medication's intended purpose.
F: Placing the patch on the same area daily can lead to skin irritation or decreased drug absorption due to buildup.
You may also like to solve these questions
A nurse is monitoring a client who is receiving a transfusion of packed RBCs. The nurse should identify which of the following findings as an indication of a febrile nonhemolytic reaction?
- A. Dyspnea
- B. Urticaria
- C. Chills
- D. Vomiting
Correct Answer: C
Rationale: The correct answer is C: Chills. A febrile nonhemolytic reaction during a blood transfusion is characterized by the sudden onset of chills and fever, usually within the first 15 minutes to 2 hours of the transfusion. This reaction is caused by the recipient's antibodies reacting to donor leukocytes. Dyspnea (A), urticaria (B), and vomiting (D) are more indicative of other transfusion reactions such as an allergic reaction, hemolytic reaction, or bacterial contamination, respectively.
A nurse is reinforcing teaching with the parents of a 13-month-old child following administration of the measles mumps rubella (MMR) Immunization. Which of the following statements by the nurse is appropriate?
- A. Your child will receive another MMR immunization and the hepatitis B immunization at 3 years of age.
- B. Your child will receive two more MMR immunizations over the next 2 years.
- C. Your child will receive another MMR immunization at 4 to 6 years of age.
- D. Your child will have an MMR titer taken to determine the need for further immunizations.
Correct Answer: C
Rationale: The correct answer is C because at 13 months, the child receives the first dose of MMR vaccine. The second dose is usually given at 4 to 6 years of age to ensure long-term immunity. Option A is incorrect as hepatitis B is not typically given at 3 years of age with MMR. Option B is incorrect because only one more dose of MMR is usually needed. Option D is incorrect because titers are not routinely done for MMR vaccine.
A nurse is planning to administer medications to a client who has trigeminal neuralgia. Which of the following medications should the nurse plan to administer to manage the client's pain?
- A. Lorazepam
- B. Fluoxetine
- C. Carbamazepine
- D. Methylphenidate
Correct Answer: C
Rationale: The correct answer is C: Carbamazepine. Carbamazepine is a first-line medication used to treat trigeminal neuralgia by reducing nerve impulses that cause pain. It is an anticonvulsant that helps relieve the sharp, shooting pain associated with this condition. Lorazepam (A) is a benzodiazepine used for anxiety and not typically indicated for trigeminal neuralgia. Fluoxetine (B) is an antidepressant that is not effective for managing the severe pain of trigeminal neuralgia. Methylphenidate (D) is a stimulant used for ADHD and would not be appropriate for treating trigeminal neuralgia.
A nurse is reinforcing teaching about the IPLEDGE program with a female client who has a new prescription for isotretinoin. The nurse should tell the client that which of the following is a requirement of the program?
- A. Clients must have a Papanicolaou test every 6 months during treatment.
- B. Sexually active female clients must use two forms of birth control during treatment.
- C. Clients must begin a daily supplement of vitamin A for 1 month prior to initiating therapy.
- D. Female clients must have a negative mammogram prior to beginning therapy.
Correct Answer: B
Rationale: The correct answer is B: Sexually active female clients must use two forms of birth control during treatment. This is a requirement of the IPLEDGE program for isotretinoin due to the teratogenic effects of the medication. Isotretinoin can cause severe birth defects if taken during pregnancy, so using two forms of birth control is crucial to prevent pregnancy while on the medication. This requirement aims to ensure the safety of the fetus.
Choices A, C, and D are incorrect because they are not specific requirements of the IPLEDGE program for isotretinoin. A Papanicolaou test every 6 months, a daily supplement of vitamin A, and a negative mammogram are not mandatory components of the program. It is essential to focus on the specific requirements outlined by the IPLEDGE program to ensure the safe use of isotretinoin.
A nurse is caring for a client who has chronic hypertension. The client's morning vital signs include BP 140/80 mm Hg, heart rate 54/min, and respiratory rate 18/min. Which of the following medications should the nurse plan to withhold?
- A. Hydrochlorothiazide
- B. Lisinopril
- C. Atenolol
- D. Aspirin
Correct Answer: C
Rationale: The correct answer is C: Atenolol. Atenolol is a beta-blocker that lowers heart rate and blood pressure. Given the client's low heart rate of 54/min, withholding atenolol is necessary to prevent further bradycardia. Hydrochlorothiazide (A) is a diuretic that helps lower blood pressure, and it can be continued. Lisinopril (B) is an ACE inhibitor used to manage hypertension, and it can be continued as well. Aspirin (D) is often prescribed for cardiovascular protection and can also be continued in this scenario.