Nokea
The staff nurse in a regional hospital is aware that a dose of parenteral ampicillin must be administered within how many hours after it has been mixed?
- A. 1 hour
- B. 4 hours
- C. 2 hours
- D. 8 hours
Correct Answer: B
Rationale: The correct answer is B (4 hours) because parenteral ampicillin should be administered within 1 hour of mixing. This is crucial to ensure efficacy and prevent bacterial growth in the solution. Choice A (1 hour) is incorrect because it does not allow enough time for administration after mixing. Choice C (2 hours) is also incorrect as it exceeds the recommended time limit. Choice D (8 hours) is incorrect as it exceeds the safe window for administration post-mixing, increasing the risk of bacterial contamination and reduced effectiveness. Thus, the optimal timeframe for administering parenteral ampicillin after mixing is within 4 hours to maintain its therapeutic benefits.
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The nurse is caring for a client who’s hypoglycemic. This client will have a blood glucose level:
- A. Below 70mg/dl
- B. Between 120 and 180mg/dl
- C. Between 70 and 120mg/dl
- D. Over 180mg/dl
Correct Answer: A
Rationale: The correct answer is A: Below 70mg/dl. Hypoglycemia is defined as a blood glucose level below 70mg/dl. Symptoms of hypoglycemia include confusion, shakiness, and sweating. Treating hypoglycemia involves administering fast-acting carbohydrates. Choices B, C, and D are incorrect because they describe blood glucose levels that are within the normal or hyperglycemic range, which are not indicative of hypoglycemia. It is essential for the nurse to recognize and promptly address hypoglycemia to prevent serious complications.
The nurse encourages a client with an immunologic disorder to eat a nutritionally balanced diet to promote optimal immunologic function. Autoimmunity has been linked to excessive ingestion of:
- A. Protein
- B. Vitamin A
- C. Fat
- D. Zinc
Correct Answer: C
Rationale: The correct answer is C: Fat. Excessive ingestion of fat has been linked to autoimmunity due to its potential to trigger inflammation in the body, which can disrupt the immune system's balance and lead to autoimmune responses. High-fat diets have been associated with increased production of pro-inflammatory molecules, impacting immune function negatively. Protein (choice A) is essential for immune function, vitamin A (choice B) supports immune responses, and zinc (choice D) is crucial for immune system regulation. However, excessive intake of these nutrients typically does not directly lead to autoimmunity like excessive fat consumption does.
A patient asks the nurse what is CYSTOCLYSIS? The best explanation would be:
- A. to increase bladder atony
- B. to maintain patency of the foley
- C. to remove blood clots from the bladder catheter
- D. to lower the specific gravity of the urine
Correct Answer: B
Rationale: Rationale:
B is correct because cystoclisis is the process of maintaining patency of a foley catheter by irrigating it with a sterile solution. This prevents blockages and promotes proper drainage.
A, C, and D are incorrect because cystoclisis is not related to increasing bladder atony, removing blood clots, or altering urine specific gravity.
The nurse is reviewing a patient’s plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient’s inability to ambulate. Which part of the diagnostic statement does the nurse need to revise?
- A. Etiology
- B. Nursing diagnosis
- C. Collaborative problem
- D. Defining characteristic
Correct Answer: C
Rationale: The correct answer is C: Collaborative problem. In the given diagnostic statement, "Impaired physical mobility related to tibial fracture as evidenced by patient’s inability to ambulate," the nurse needs to revise the mention of collaborative problem. The collaborative problem is a health issue that requires the expertise of multiple healthcare providers, whereas the statement provided focuses on a nursing diagnosis related to physical mobility impairment. The etiology (cause), nursing diagnosis, and defining characteristic are all relevant to the nursing diagnostic statement and do not need revision. The collaborative problem aspect is not appropriate in this context as it does not fit the criteria for a collaborative problem.
A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data?
- A. The patient can now perform the dressing changes without help.
- B. The patient can begin retaking all of the previous medications.
- C. The patient is apprehensive about discharge.
- D. The patient’s surgery was not successful.
Correct Answer: C
Rationale: The correct answer is C because the patient expressing fear of going home and being alone indicates apprehension about discharge. This inference is based on the patient's subjective feelings and concerns, which are important to address for a safe discharge. Choices A and B are incorrect as they assume the patient's readiness for independent tasks without considering their emotional state. Choice D is incorrect as there is no objective data provided to support the assumption that the surgery was not successful. It is important for the nurse to acknowledge and address the patient's emotional needs before discharge.