A nurse is preparing to administer nitroglycerin topical ointment to a client. Which of the following actions should the nurse plan to take?

Measure the dosage of medication using the applicator paper.

Spread the medication over a 12.7 cm (5 in) area of the client's skin.

Cover the medication on the client's skin with a sterile gauze pad.

Apply the medication to the same site for three consecutive days.

Answer and Explanation

The Correct Answer is B

Choice A Reason:
Using the applicator paper is appropriate for measuring the dosage accurately, but simply measuring the dosage is not the only step; the medication needs to be spread over the specified area of the skin.
Choice B Reason:
Spread the medication over a 12.7 cm (5 in) area of the client's skin. Nitroglycerin ointment is typically measured using a specific paper or measuring tape provided with the medication to ensure accurate dosing. The ointment is spread thinly and evenly over a specific measured area of the skin, usually about 12.7 cm (5 inches) in length, to maintain consistent dosing.
Choice C Reason:
Covering the medication with a sterile gauze pad is not typically done with nitroglycerin ointment. The ointment is meant to be absorbed through the skin, and covering it may interfere with its absorption.
Choice D Reason:
Nitroglycerin ointment is often applied to different sites to prevent skin irritation and tolerance from developing at one site. It's usually rotated to different clean areas of the skin to prevent skin irritation and tolerance buildup. Applying it to the same site for three consecutive days is not standard practice.

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Correct Answer is D

Explanation

Choice A Reason:
. "I will check the client's INR before administering the heparin." Is incorrect. Checking the client's INR (International Normalized Ratio) is essential, but it's more applicable for monitoring anticoagulants like warfarin, not heparin. Heparin's effect is typically monitored via activated partial thromboplastin time (aPTT) or anti-Xa levels, not INR.
Choice B Reason:
"I will aspirate before administering the heparin." Is incorrect. Aspirating before administering heparin injections is not necessary because the medication is given subcutaneously or intravenously and not into a blood vessel.
Choice C Reason:
"I will massage the site after injecting the heparin." Is incorrect. Massaging the site after injecting heparin could increase the risk of bruising or hematoma formation at the injection site. It's generally advised to avoid massaging the area after a heparin injection to prevent tissue trauma.
Choice D Reason:
"I will apply pressure for 1 minute after the injection." Is correct. Applying pressure to the injection site for about a minute after administering heparin helps minimize the risk of bleeding or hematoma formation, especially with subcutaneous injections. This practice aids in reducing bleeding at the injection site.

A. Nausea B. Insomnia C. Laryngeal edema D. Cardiac dysrhythmia

Correct Answer is C

Explanation

Choice A Reason:
Nausea is incorrect. Nausea is a common side effect of many medications, including antibiotics like amoxicillin. While it can be a side effect of an allergic reaction, it's also a general symptom that can occur due to various reasons, such as gastrointestinal upset or the direct effects of the antibiotic on the stomach lining. Nausea alone is less specific for indicating an allergic reaction compared to severe symptoms like laryngeal edema.
Choice B Reason:
Insomnia is incorrect. Insomnia, or difficulty sleeping, is not a typical manifestation of an allergic reaction to amoxicillin. Allergic reactions usually involve more immediate and visible symptoms such as skin rash, itching, swelling, difficulty breathing, or in severe cases, anaphylaxis. Insomnia is not a common symptom associated with allergic responses to antibiotics.
Choice C Reason:
Laryngeal edema is correct. Laryngeal edema, or swelling of the larynx, is a serious symptom of an allergic reaction known as anaphylaxis. This severe allergic reaction can be life-threatening due to its potential to obstruct the airway, leading to breathing difficulties.
Choice D Reason:
Cardiac dysrhythmia is incorrect. While medications can sometimes affect heart rhythms, cardiac dysrhythmia is not a common symptom of an allergic reaction to amoxicillin. Allergic reactions tend to manifest with more immediate symptoms like skin reactions, respiratory issues, or swelling rather than primarily affecting the heart rhythm.

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A nurse is preparing to administer nitroglycerin topical ointment to a client. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is teaching a newly licensed nurse about administering heparin to a client. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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