Rationale: The timing of insulin’s effects varies according to the type. Referring to the chart, the nurse would note that the onset of action for the intermediate insulin is 2 to 4 hours. Because the administration time was 0800, the effects should begin 2 hours after administration, at 1000.
02.Answer: a
Rationale: The assessment findings of pallor,swelling, skin that’s cool to the touch at the I.V. insertion site, and a normal white blood cell count all indicate infiltration. The infusion should be discontinued and restarted in a different site. Phlebitis would be evidenced by redness at the cannula tip and along the vein. Infection would be evidenced by an elevated white blood cell count.
03.Answer: b, c, d, e, f
Rationale: A nurse must always implement safe nursing practice when administering medications. Following the rights of medication administration helps protect the client from medication errors. Safe procedure includes confirming the right client, dose, medication, time, and route. Confirming the room number doesn’t guarantee that the right client will receive the correct medication
04.Answer: a, c, d
Rationale: Reducing dietary sodium intake will help increase the effectiveness of diuretic medication and may allow smaller doses to be ordered. Diuretics are commonly prescribed to control fluid accumulation in the body; therefore, the presence of edema may indicate the need for the physician to adjust the therapy.
Compliance is very important with diuretics. In order to effectively monitor therapy, the nurse should encourage the client to take the medication exactly as prescribed.Salt substitutes aren’t recommended because they contain potassium instead of sodium and may cause serious cardiovascular effects. Diuretics cause an increased urine output, which may interfere with the client’s sleep if taken at bedtime.
05.Answer: a, b, c
Rationale: Metoprolol masks the common signs of hypoglycemia;therefore, glucose levels should be monitored closely in diabetic clients. When used to treat an MI, metoprolol is contraindicated in clients with heart rates less than 45 beats/minute and any degree of heart block, so the nurse should monitor the client for
bradycardia and heart block. Metoprolol masks common signs and symptoms of shock, such as decreased blood pressure, so blood pressure should also be monitored closely. The nurse should give the drug undiluted by direct injection. Although metoprolol shouldn’t be mixed with other drugs, studies have shown that it’s compatible when mixed with morphine sulfate or when administered with alteplase infusion at a Y-site connection.
06.Answer: b, e, f
Rationale: Redness, warmth, pain, and a hard, cordlike vein at the I.V. insertion site suggest that the client
has phlebitis. The nurse should discontinue the I.V. infusion and insert a new I.V. catheter proximal to or above the discontinued site or in the other arm. Applying warm soaks to the site reduces inflammation. The nurse should document the assessment of the I.V. site,the actions taken, and client’s response to the situation.Slowing the infusion rate won’t reduce the phlebitis. Restarting the infusion at a site distal to the
phlebitis may contribute to the inflammation. Skin sloughing isn’t a symptom of phlebitis; it’s associated with extravasation of certain toxic medications.
07.Answer: 8
Rationale: The nurse should calculate the infusion rate using the following formula:
Dose on hand/Quantity on hand = Dose desired/X
25,000 units/250 ml = 800 units/hour X
25,000 units x X = 250 ml x 800 units/hour
25,000 x X = 200,000 ml/hour
X =8 ml/hour
08.Answer: 50
Rationale: The nurse should use the following equation to calculate the drip rate:
Total quantity/Administration time x gtt/min = X
100 ml/30 min x 15 gtt/min = X
1500 gtt
X = 30 min
X = 50 gtt/minute
09.Answer: c, d, f
Rationale: Administer an I.V. bolus by slow (50 mg/minute) I.V. push; too rapid an injection may cause hypotension and circulatory collapse. Continuous monitoring of ECG, blood pressure, and respiratory status is essential when administering phenytoin I.V.Early toxicity may cause drowsiness, nausea, vomiting,nystagmus, ataxia, dysarthria, tremor, and slurred speech. Later effects may include hypotension, arrhythmias,respiratory depression, and coma. Death may result from respiratory and circulatory depression.Phenytoin shouldn’t be administered by I.V. push in veins on the back of the hand; larger veins are needed to prevent discoloration associated with purple glove syndrome. Mix I.V. doses in normal saline solution and use the solution within 30 minutes; doses mixed in dextrose 5% in water will precipitate. Use of an inline filter is recommended.
10.Answer: a, d, f
Rationale: The nurse should tell the client to avoid salt substitutes because they may contain potassium, which can cause light-headedness and syncope. Facial swelling or difficulty breathing should be reported immediately because they may be signs of angioedema, which would require discontinuation of the drug. The client should also be advised to change position slowly to minimize orthostatic hypotension. The nurse should tell the client to report light-headedness, especially during the first few days of therapy, so dosage adjustments can be made. The client should also report signs of infection,such as sore throat and fever, because the drug may decrease the white blood cell (WBC) count. Because this effect is generally seen within 3 months, the WBC count and differential should be monitored periodically.
11.Answer d
Rational: Cough and shortness of breath are significant symptoms because they may indicate decreasing pulmonary function secondary to drug toxicity. Decrease in appetite, difficulty in thinking clearly, and spasms of the diaphragm may occur as a result of chemotherapy; however,they are not indicative of pulmonary toxicity.
12.Answer a
Rational: Signs of infiltration include slowing of the infusion and swelling, pain, hardness, pallor, and coolness of the skin at the site.If these signs occur, the I.V. line should be discontinued and restarted at another infusion site. The new anatomic site, time, and type of cannula used should be documented. The nurse may apply a warm soak to the site, but only after the I.V. line is discontinued.Parenteral administration of fluids should not be stopped intermittently. Stopping the flow does not treat the problem, nor does it address the client's needs for fluid replacement. Infiltrated I.V. sites should not be irrigated; doing so will only cause more swelling and pain.
13.Answer b
Rational: TPN is hypertonic, high-calorie, high-protein, intravenous (IV) fluid that should be provided to clients without functional gastrointestinal tract motility, to better meet their metabolic needs and to support optimal nutrition and healing. TPN is ordered once daily, based on the client's current electrolyte and fluid balance, and must be handled with strict aseptic technique (because of its high glucose content, it is a perfect medium for bacterial growth). Also, because of the high tonicity, TPN must be administered through a central venous access, not a peripheral IV line. There is no specific need to auscultate for bowel sounds to determine whether TPN can safely be administered.
14.Answer d
Rational: Isoniazid competes for the available vitamin B6 in the body and leaves the client at risk for developing neuropathies related to vitamin deficiency. Supplemental vitamin B6 is routinely prescribed to address this issue. Avoiding sun exposure is a preventive measure to lower the risk of skin cancer. Following a low-cholesterol diet lowers the individual's risk of developing atherosclerotic plaque. Rest is important in maintaining homeostasis but has no real impact on neuropathies.
15.Answer d
Rational: When giving an I.M. injection, the nurse inserts the needle into the muscle at a 90-degree angle, using a quick, dartlike motion. A 15-degree angle is appropriate when dministering an intradermal injection. A 30-degree angle isn't used for any type of injection. The nurse may use a 45- or 90 degree angle when giving a subcutaneous injection.
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