A nurse is teaching a client who has pernicious anemia to self-administer nasal cyanocobalamin. Which of the following information should the nurse include in the teaching?

"Lie down for 1 hour after administering the medication."

"Administer the medication into one nostril once per week,

"Plan to self-administer this medication for the next 6 months

"Use a nasal decongestant 15 minutes before the medication if you have a stuffy nose

Answer and Explanation

The Correct Answer is B

A. "Lie down for 1 hour after administering the medication.": This statement is not necessary for nasal cyanocobalamin administration. There is no need for the client to lie down for an extended period after administering the medication.
B. "Administer the medication into one nostril once per week.": This is the correct information. Nasal cyanocobalamin is typically administered once a week for the treatment of pernicious anemia. It's important for the nurse to emphasize the correct frequency and route of administration to ensure the effectiveness of the treatment.
C. "Plan to self-administer this medication for the next 6 months.": The duration of treatment may vary based on the healthcare provider's prescription. The nurse should instruct the client based on the specific instructions provided by the healthcare provider rather than a predetermined time frame.
D. "Use a nasal decongestant 15 minutes before the medication if you have a stuffy nose.": This statement is not a standard recommendation for nasal cyanocobalamin administration. If the client has concerns about a stuffy nose, they should consult with their healthcare provider rather than using a nasal decongestant without guidance.

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Correct Answer is D

Explanation

A. Dark amber urine:
Dark amber urine is not typically an adverse effect of receiving 0.9% sodium chloride solution. It may be a sign of concentrated urine, dehydration, or the presence of certain substances, but it is not a direct adverse effect of the solution itself.
B. Decreased skin turgor:
Decreased skin turgor is a clinical manifestation of dehydration and is not an adverse effect of 0.9% sodium chloride solution. The solution is administered to address dehydration and restore fluid balance.
C. Increased bowel sounds:

Increased bowel sounds are not an adverse effect of 0.9% sodium chloride solution. Bowel sounds are influenced by various factors, including the presence of gas and peristalsis, but they are not directly related to the administration of this isotonic solution.
D. Pink, frothy sputum:
This is the correct answer. Pink, frothy sputum is a potential sign of pulmonary edema, which can be associated with fluid overload. Administering 0.9% sodium chloride solution too rapidly or in excessive amounts can lead to fluid overload and pulmonary edema.

A. A client received 0900 medications at 0930. B. A client who has asthma was administered tiotropium via inhalation. C. A client received a blood transfusion with dextrose 5% in water. D. A client received an infusion of lipids through a central line

Correct Answer is C

Explanation

A. A client received 0900 medications at 0930:
This situation involves a medication administration error where the medications were administered later than the scheduled time. An incident report should be completed to document the error, investigate the circumstances, and implement measures to prevent recurrence.
B. A client who has asthma was administered tiotropium via inhalation:
Tiotropium is an appropriate medication for asthma. As long as it was administered according to the prescribed guidelines, there is no need for an incident report.
C. A client received a blood transfusion with dextrose 5% in water:
This situation involves a significant medication error, as dextrose 5% in water is not the appropriate solution for a blood transfusion. An incident report should be completed to document the error, investigate the circumstances, and implement measures to prevent recurrence.
D. A client received an infusion of lipids through a central line:
If the infusion of lipids through a central line was ordered and administered appropriately, there is no need for an incident report. Lipid infusions are commonly administered through central lines when indicated.

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A nurse is teaching a client who has pernicious anemia to self-administer nasal cyanocobalamin. Which of the following information should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving 0.9% sodium chloride solution to treat dehydration. Which of the following findings should the nurse identify as an adverse effect of the solution?

Correct Answer is D

Explanation

A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report?

Correct Answer is C

Explanation

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