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 sho
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1. 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: C

Rationale: Flushing and tachycardia are signs of Red Man Syndrome, which can be mitigated by decreasing the infusion rate.

2. A client with tobacco use disorder is being educated about Nicotine replacement therapy. Which statement by the client indicates an understanding of the teaching?

Correct answer: A

Rationale: The correct answer is A. To maximize the effectiveness of nicotine gum, the client should avoid eating or drinking 15 minutes before and while using it. This helps ensure proper absorption of nicotine through the oral mucosa. Choice B is incorrect because the duration of nicotine gum use can vary depending on the individual's needs and progress. Choice C is incorrect as nicotine gum should be used during pregnancy only under healthcare provider guidance. Choice D is incorrect because nicotine gum should be chewed slowly until a tingling sensation is felt, then parked between the cheek and gum until the tingling stops.

3. A client has a new prescription for nitroglycerin transdermal patches. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: The correct instruction for a client using nitroglycerin transdermal patches is to remove the patch every night before bedtime. This practice helps prevent tolerance to the medication's effects. Continuous exposure to nitroglycerin can result in the body becoming less responsive to its therapeutic effects over time, reducing its efficacy in managing the prescribed condition. Choices A, C, and D are incorrect. Applying the patch to a different location each day does not address the issue of tolerance. Massaging the patch area gently after application is not recommended as it may alter drug absorption. Shaving the area before applying the patch is unnecessary and may increase the risk of skin irritation.

4. A client has been taking Phenylephrine nasal drops for the past 10 days for Sinusitis. The nurse should assess the client for which of the following adverse effects of this medication?

Correct answer: B

Rationale: The correct answer is B: Nasal congestion. After more than 5 days of use, nasal sympathomimetic medications like phenylephrine can lead to rebound nasal congestion. This occurs due to prolonged vasoconstriction of nasal blood vessels, causing worsening nasal congestion. Sedation (choice A) is not a common adverse effect of phenylephrine nasal drops. Productive cough (choice C) and constipation (choice D) are also not typical adverse effects associated with this medication.

5. Following a stroke, a client has been started on clopidogrel (Plavix). Why is this medication being administered?

Correct answer: D

Rationale: Clopidogrel (Plavix) is an antiplatelet medication that inhibits platelet aggregation, reducing the risk of blood clots. It is commonly used in patients who have had a stroke and cannot tolerate aspirin due to allergies or intolerances. Choosing clopidogrel in these cases helps prevent further clot formation and reduces the risk of recurrent strokes.

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