A nurse is reviewing data for a client who receives clonidine daily.
Which of the following findings indicates the nurse should withhold the next dose?

Urine output 600 mL in 8 hr.

Blood pressure 88/50 mm Hg.

Heart rate 110/min.

Blood glucose 70 mg/dL.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

A urine output of 600 mL in 8 hours is within the normal range. The average urine output for adults is about 1 to 2 liters per day.

Choice B rationale:

Clonidine is an antihypertensive medication. If the client’s blood pressure is already low (88/50 mm Hg), administering clonidine could further lower the blood pressure and cause hypotension.

Choice C rationale:

A heart rate of 110/min is slightly high, but it’s not a direct indication to withhold clonidine. Clonidine can actually help lower an elevated heart rate by reducing the levels of certain chemicals in your blood.

Choice D rationale:

A blood glucose level of 70 mg/dL is at the lower end of the normal range (70-100 mg/dL) However, clonidine does not directly affect blood glucose levels, so this would not be a reason to withhold the medication.

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Correct Answer is D

Explanation

Choice Arationale:

Aspiration (pulling back on the syringe before injection) is not recommended when administering enoxaparin. This could cause bruising.

Choice Brationale:

You should not massage the site following the injection as this could cause bruising.

Choice Crationale:

With enoxaparin and other low molecular weight heparins, you do not need to expel the air bubble before injecting the medication. The air bubble ensures that all the medication is delivered.

Choice D rationale:

Enoxaparin should be injected into abdominal tissue. This helps ensure proper absorption and reduces the risk of bruising.

A. "My voice is no longer hoarse.” B. "I am feeling more alert.” C. "I don't have a headache anymore.” D. "My appetite is increased.”

Correct Answer is A

Explanation

Choice A rationale:

Hoarseness of voice can be a symptom of an allergic reaction, indicating swelling and inflammation in the throat. If the client’s voice is no longer hoarse after taking diphenhydramine, it suggests that the medication has been effective in reducing this symptom.

Choice B rationale:

Diphenhydramine is an antihistamine and can often cause drowsiness as a side effect. Therefore, feeling more alert would not typically indicate that the medication has been effective.

Choice C rationale:

While headaches can sometimes be associated with allergic reactions, they are not a primary symptom that diphenhydramine targets. Therefore, absence of a headache does not necessarily indicate effectiveness of the medication.

Choice D rationale:

Increased appetite is not typically associated with the effectiveness of diphenhydramine in treating allergic reactions.

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A nurse is reviewing data for a client who receives clonidine daily.Which of the following findings indicates the nurse should withhold the next dose?

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer enoxaparin subcutaneously to a client using a prefilled syringe. The nurse should plan to use which of the following techniques when administering this medication?

Correct Answer is D

Explanation

A nurse is collecting data from a client who received diphenhydramine 1 hr ago after developing an allergic reaction to trimethoprim-sulfamethoxazole.Which of the following statements by the client should indicate to the nurse that the medication is effective?

Correct Answer is A

Explanation

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A nurse is reviewing data for a client who receives clonidine daily.
Which of the following findings indicates the nurse should withhold the next dose?