Nokea
A nurse is preparing to administer methylprednisolone acetate (Depo-Medrol) 10 mg by IV bolus. The amount available is 40 mg/mL. How many mL should the nurse administer?
Correct Answer: 0.3
Rationale: Correct Answer: 0.3 mL
Rationale:
1. Calculate the total dose needed: 10 mg.
2. Determine the concentration: 40 mg/mL.
3. Use the formula: dose needed / concentration available = volume to administer.
4. Plug in the values: 10 mg / 40 mg/mL = 0.25 mL.
5. Round up to the nearest practical dose increment: 0.3 mL.
Summary:
Choice A (0.5 mL): Incorrect, as it does not accurately calculate the volume needed.
Choices B-G: Irrelevant, as they do not follow the correct calculation method.
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A goal for a client who has difficulty w/self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral w/which of the following members of the interprofessional care team?
- A. Social worker
- B. Certified nursing assistant
- C. Registered dietitian
- D. Occupational therapist
Correct Answer: D
Rationale: The correct answer is D: Occupational therapist. Occupational therapists specialize in helping individuals with physical limitations to maximize their ability to perform daily activities, such as self-feeding. They can assess the client's specific needs, recommend appropriate adaptive devices, and provide training on how to use them effectively. Social workers (A) focus more on psychosocial support, certified nursing assistants (B) provide direct care but may not have the expertise in adaptive devices, and registered dietitians (C) focus on nutrition-related issues. Therefore, the occupational therapist (D) is the most appropriate member of the interprofessional care team to address the client's self-feeding difficulties due to rheumatoid arthritis.
A nurse is assessing the pain level of a client who has come to the ER reporting severe abdominal pain. The nurse asks the client whether he has nausea & has been vomiting. The nurse is assessing which of the following?
- A. Presence of associated symptoms
- B. Location of the pain
- C. Pain quality
- D. Aggravating & relieving factors
Correct Answer: A
Rationale: The correct answer is A: Presence of associated symptoms. By asking about nausea and vomiting, the nurse is assessing for other symptoms that may accompany the abdominal pain, providing crucial information for a comprehensive assessment. This helps in identifying potential causes, such as gastrointestinal issues. Other choices are incorrect because B: Location of the pain, C: Pain quality, and D: Aggravating & relieving factors focus solely on the characteristics of pain itself and not on associated symptoms.
A nurse is caring for a client diagnosed w/severe acute respiratory syndrome (SARS). The nurse is aware that health care professionals are required to report communicable & infectious diseases. Which of the following illustrate the rationale for reporting? Select all.
- A. Planning & evaluating control & prevention strategies
- B. Determining public health priorities
- C. Ensuring proper medical treatment
- D. Identifying endemic disease
- E. Monitoring for common-source outbreaks
Correct Answer: A, B, C, E
Rationale: The correct answers are A, B, C, and E. Reporting communicable diseases like SARS is crucial for planning and evaluating control and prevention strategies. It helps in determining public health priorities by identifying trends and areas that require attention. Reporting ensures proper medical treatment for the affected individuals and their contacts, preventing further spread. Additionally, monitoring for common-source outbreaks allows for timely intervention to limit the spread of the disease. Choices D, F, and G are incorrect as they do not directly relate to the rationale for reporting communicable diseases in this context.
A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy & unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when she was not on break. Which of the following actions should the nurse take?
- A. Remind the nurse that safe client care is a priority on the unit
- B. Ask others on the team whether they have observed the same behavior
- C. Report observations to the nurse manager on the unit
- D. Conclude that her coworker's fatigue is not her problem to solve
Correct Answer: C
Rationale: The correct action is to choose option C: Report observations to the nurse manager on the unit. This is the most appropriate course of action because it addresses the potential safety risk to patients due to the drowsy nurse's behavior. Reporting to the nurse manager ensures that the issue is escalated to someone in authority who can address it effectively, such as through a conversation with the drowsy nurse, adjusting their work schedule, or providing support if there are underlying issues causing the fatigue. Options A, B, and D are not as effective because reminding the nurse or asking others on the team may not lead to a resolution, and assuming the fatigue is not the nurse's problem to solve ignores the potential impact on patient safety.
A nurse is obtaining history from a client who has pain. The nurse's guiding principle throughout this process should be that:
- A. Some clients exaggerate their level of pain
- B. Pain must have an identifiable source to justify the use of opioids.
- C. Objective data are essential in assessing pain
- D. Pain is whatever the client says it is.
Correct Answer: D
Rationale: Step-by-step rationale for why answer D is correct:
1. Pain is a subjective experience: Pain perception varies among individuals, making it crucial to consider the client's own description.
2. Client-centered care: Acknowledging the client's self-report of pain is essential in providing effective and compassionate care.
3. Holistic approach: Recognizing the client's perspective on pain helps in addressing their physical, emotional, and psychological needs.
4. Trust and rapport: Valuing the client's self-assessment of pain fosters a trusting relationship between the nurse and the client.
5. Evidence-based practice: Research supports that self-reporting of pain is the most reliable indicator of pain intensity.
Summary:
- Choice A is incorrect as assuming clients exaggerate pain undermines their credibility and may lead to inadequate pain management.
- Choice B is incorrect as pain is not always identifiable, and opioids may be justified based on the client's report.
- Choice C is incorrect as relying solely on objective data overlooks the