A nurse in a provider's office is assisting in the care of a client.
Which of the following instructions should the nurse include when reinforcing teaching to the client about their medication? Select all that apply.
Remove the patch if you experience a headache.
Lie down with feet elevated if dizziness occurs while taking this medication.
The medication will be effective 30 to 45 min following application
Apply the patch daily to a hairless area of the skin.
Remove the patch 12 to 14 hr following application.
Place the patch on the same area every day.
Correct Answer : A,B,C,D,E
A. Headache is a common side effect of nitroglycerin, and if it becomes severe or persistent, the client should remove the patch and seek medical advice.
B. Nitroglycerin can cause dizziness or lightheadedness, especially when changing positions. If the client experiences dizziness, lying down with feet elevated can help alleviate symptoms and prevent falls.
C. Nitroglycerin patches typically take about 30 to 45 minutes to begin working after application. This information helps the client understand the expected onset of action of the medication.
D. Nitroglycerin patches should be applied to a clean, hairless area of the skin, usually on the chest or upper arm, to ensure optimal absorption of the medication.
E. Nitroglycerin patches are typically worn for 12 to 14 hours at a time and then removed for a nitrate- free period to prevent tolerance. Following this schedule helps maintain the effectiveness of the medication.
F. To prevent skin irritation or tolerance to the medication, it is recommended to rotate the application site of the nitroglycerin patch with each new patch. This helps ensure consistent absorption and effectiveness of the medication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Before administering any medication, the nurse should positively identify the client using at least two unique identifiers (e.g., name, date of birth, medical record number). Positive identification helps prevent medication errors and ensures that the medication is administered to the intended recipient.
A. Validating the prescription with the available medication is an important step to ensure that the correct medication is being administered. However, before doing so, it's essential to confirm the identity of the client and the correct time for administration.
B. Calculating the correct amount of medication is necessary to ensure that the client receives the appropriate dose. However, before performing this calculation, it's essential to confirm the identity of the client and the correct time for administration.
C. Documenting the time of medication administration is important for maintaining an accurate record of the client's medication administration history. However, before documenting, it's crucial to confirm the identity of the client and the correct time for administration.
Correct Answer is A
Explanation
A. When administering a TST, the nurse should select an injection site that is free of scar tissue and areas with excessive hair, veins, or visible lesions. The preferred site for TST administration is the volar aspect of the forearm, approximately 2-4 inches below the elbow.
B. After administering the TST, the nurse should not massage or manipulate the injection site. Massaging the site can cause irritation or spread the solution, leading to inaccurate results.
C. he TST is administered intradermally, typically with a 27-gauge needle. The needle should be inserted with the bevel facing upward at a 5-15-degree angle.
D. The standard dose of tuberculin solution (e.g., purified protein derivative, PPD) for a TST is 0.1 mL containing 5 tuberculin units (TU).
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