A nurse is teaching a female client who has a new prescription for transdermal sumatriptan to treat migraine headaches. Which of the following instructions should the nurse include?

Activate the patch 30 minutes after application.

Take this medication daily to prevent headaches.

Use contraception while taking this medication.

You can bathe with the patch in place.

Answer and Explanation

The Correct Answer is C

Choice A reason: Activate the patch 30 minutes after application

This statement is incorrect. The transdermal sumatriptan patch should be activated immediately after application, not 30 minutes later. The patch uses a mild electrical current to deliver the medication through the skin, and delaying activation would reduce its effectiveness.

Choice B reason: Take this medication daily to prevent headaches

This statement is also incorrect. Sumatriptan is used to treat acute migraine attacks and is not intended for daily use to prevent headaches. It should be used only when a migraine begins. Daily use could lead to medication overuse headaches and other side effects.

Choice C reason: Use contraception while taking this medication

This statement is correct. Women of childbearing age should use contraception while taking sumatriptan because its safety during pregnancy has not been established. It is important to avoid potential risks to the fetus.

Choice D reason: You can bathe with the patch in place

This statement is correct. The transdermal sumatriptan patch is designed to stay in place during bathing, showering, or swimming. However, it is not the most critical piece of information compared to the need for contraception.

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Correct Answer is A

Explanation

Choice A reason: 90 bpm is the threshold below which the nurse should withhold digoxin for a 6-month-old infant. Digoxin can slow the heart rate, and administering it when the heart rate is already low can increase the risk of bradycardia, a serious heart rhythm disturbance.

Choice B reason: 100 bpm is above the threshold for withholding digoxin in a 6-month-old infant. While it is important to monitor the heart rate, digoxin can be safely administered if the apical heart rate is above 90 bpm.

Choice C reason: 110 bpm is also above the threshold for withholding digoxin. This heart rate indicates that the infant’s heart rate is within a safe range for administering the medication.

Choice D reason: 120 bpm is well above the threshold for withholding digoxin. This heart rate is considered safe for administering the medication, as it indicates the heart rate is not too low.

A. Decrease the infusion rate. B. Change the IV infusion site. C. Document that the client experienced an anaphylactic reaction to the medication. D. Apply cold compresses to the neck area.

Correct Answer is A

Explanation

Choice A reason:

Decreasing the infusion rate is the appropriate action when a client experiences flushing and tachycardia while receiving IV vancomycin. These symptoms are indicative of “Red Man Syndrome,” a reaction that occurs when vancomycin is infused too quickly. Slowing the infusion rate can help alleviate these symptoms and prevent further complications.

Choice B reason:

Changing the IV infusion site is not necessary in this situation. The symptoms of flushing and tachycardia are related to the rate of vancomycin infusion, not the site of administration. Therefore, changing the site would not address the underlying issue.

Choice C reason:

Documenting that the client experienced an anaphylactic reaction to the medication is incorrect. Anaphylaxis is a severe, life-threatening allergic reaction that involves symptoms such as difficulty breathing, swelling of the face and throat, and a rapid drop in blood pressure. The symptoms described (flushing and tachycardia) are more consistent with Red Man Syndrome, not anaphylaxis.

Choice D reason:

Applying cold compresses to the neck area is not an effective intervention for managing the symptoms of Red Man Syndrome. The primary approach should be to slow the infusion rate of vancomycin. Cold compresses would not address the cause of the reaction.

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A nurse is teaching a female client who has a new prescription for transdermal sumatriptan to treat migraine headaches. Which of the following instructions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer digoxin to a 6-month-old infant. Prior to administering the dose, the nurse measures the apical heart rate. The nurse should withhold the dose if the infant’s apical heart rate is less than what rate?

Correct Answer is A

Explanation

A nurse is assessing a client who is receiving IV vancomycin. The nurse notes a flushing of the neck and tachycardia. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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