Nokea
A healthcare professional is preparing to administer gentamicin 2 mg/kg via IV bolus to a client who weighs 220 lb. How many mg should the healthcare professional administer?
- A. 200 mg
- B. 100 mg
- C. 160 mg
- D. 180 mg
Correct Answer: C
Rationale: To calculate the dosage correctly, the weight in pounds must first be converted to kilograms. 220 lb / 2.2 = 100 kg. Then, multiply the weight in kg by the dosage of 2 mg/kg: 2 mg/kg 100 kg = 200 mg. Therefore, the correct dosage to administer is 200 mg, which is closest to option A. Option C (160 mg) is incorrect because it does not match the calculated dosage. Options B (100 mg) and D (180 mg) are also incorrect as they do not align with the correct calculation.
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The healthcare provider is planning care for a 14-year-old client returning from scoliosis corrective surgery. Which of the following actions should receive priority in the plan?
- A. Administer antibiotic therapy for 10 days
- B. Teach the client isometric exercises for legs
- C. Assess movement and sensation of extremities
- D. Assist the client to stand up at the bedside within the first 24 hours
Correct Answer: C
Rationale: Assessing movement and sensation of extremities is the priority after scoliosis corrective surgery as it helps in early detection of any neurological deficits that may have occurred during the procedure. This assessment is essential for prompt intervention if any issues are identified. Administering antibiotics, teaching exercises, and assisting the client to stand up are important aspects of care but assessing neurological status takes precedence to ensure the client's safety and recovery.
A client has just returned from surgery with an indwelling urinary catheter in place. What is the most important action for the nurse to take to prevent infection?
- A. Change the catheter every 72 hours.
- B. Ensure the catheter tubing is free of kinks.
- C. Clean the perineal area with antiseptic solution daily.
- D. Irrigate the catheter with normal saline every shift.
Correct Answer: B
Rationale: The most crucial action to prevent infection in a client with an indwelling urinary catheter is to ensure the catheter tubing is free of kinks. Kinks in the tubing can lead to urine retention or obstruction, increasing the risk of infection. Changing the catheter every 72 hours is not necessary if there are no signs of infection or other issues. Cleaning the perineal area with antiseptic solution daily is important for hygiene but not the most critical action to prevent infection related to the catheter. Irrigating the catheter with normal saline every shift is not a routine practice and may increase the risk of introducing pathogens into the urinary system.
A client is experiencing dehydration, and the nurse is planning care. Which of the following actions should the nurse include?
- A. Administer antihypertensives as prescribed.
- B. Check the client's weight daily.
- C. Notify the provider if the urine output is less than 30 mL/hr.
- D. Encourage the client to ambulate independently four times a day.
Correct Answer: B
Rationale: Checking the client's weight daily is essential for monitoring fluid status in dehydration. Administering antihypertensives, notifying the provider of insufficient urine output, and encouraging ambulation are not primary interventions for managing dehydration. Administering antihypertensives may affect blood pressure, but it is not a direct intervention for dehydration. Notifying the provider of a urine output less than 30 mL/hr indicates oliguria, which is a sign of reduced kidney function rather than dehydration. Encouraging ambulation is a general nursing intervention and does not directly address the fluid imbalance associated with dehydration.
A client with heart failure and a new prescription for hydrochlorothiazide is receiving discharge teaching about safety considerations from a nurse. Which statement by the client indicates an understanding of the teaching?
- A. "I will take a hot bath before going to bed."
- B. "I will take my new medication in the evening."
- C. "I will leave a light on in my bathroom at night."
- D. "I will weigh myself once weekly."
Correct Answer: C
Rationale: The correct answer is C. Leaving a light on in the bathroom at night is important for an older adult with heart failure who is taking hydrochlorothiazide, a diuretic that can cause nocturia. This safety measure helps prevent falls during nighttime bathroom visits. Option A is incorrect because taking a hot bath before bed can increase the risk of falls due to potential dizziness. Option B does not directly relate to safety considerations but rather the timing of medication administration. Option D, weighing oneself once weekly, is important for monitoring fluid retention but does not address safety concerns related to nocturia and falls.
A charge nurse is assigning tasks to a nurse and assistive personnel for a group of clients. Which of the following tasks should the charge nurse delegate to the AP?
- A. Report ABG results to the provider
- B. Instruct a client about how to use an incentive spirometer
- C. Administer an enteral feeding to a client who has an established gastrostomy tube
- D. Monitor the color of a client's urinary output
Correct Answer: D
Rationale: The correct answer is D because monitoring the color of a client's urinary output is a task that can be safely delegated to assistive personnel. This task involves basic observation and does not require specialized nursing knowledge or skills. Choice A is incorrect because reporting ABG results to the provider requires interpretation and critical thinking skills typically performed by a nurse. Choice B is incorrect as instructing a client about how to use an incentive spirometer involves educating and assessing the client, which is a nursing responsibility. Choice C is incorrect as administering enteral feeding to a client with a gastrostomy tube requires nursing expertise to ensure proper technique and monitoring for complications.