Nokea
A 32 year-old male with a complaint of dizziness has an order for Morphine via. IV. The nurse should do which of the following first?
- A. Check the patient's chest x-ray results.
- B. Retake vitals including blood pressure.
- C. Perform a neurological screen on the patient.
- D. Request the physician on-call assess the patient.
Correct Answer: B
Rationale: Dizziness can be a sign of hypotension, that may a contraindication with Morphine.
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The physician orders the antibiotics ampicillin (Omnipen) and gentamicin (Garamycin) for a newly admitted client with an infection. The nurse should:
- A. administer both medications simultaneously.
- B. give the medications sequentially, and flush well between them.
- C. ask the physician or pharmacy which medication to give first and how long to wait before giving the other drug.
- D. start one medication now and begin the other medication in 2-4 hours.
Correct Answer: B
Rationale: A client with an infection needs both antibiotics as soon as possible. However, the pH of ampicillin is 8-10, and the pH of gentamicin is 3-5.5 (making them incompatible when given together). Flushing well between drugs is necessary.
Which of the following infant behaviors demonstrates the concept of object permanence?
- A. The infant cries when his mother leaves the room.
- B. The infant looks at the floor to find a toy that he was playing with and dropped.
- C. The infant picks up another toy after the one he was playing with rolls under the couch.
- D. The infant participates in a game of patty-cake.
Correct Answer: B
Rationale: Object permanence occurs when the infant learns that something/someone still exists even though they might not be able to see it/them. This develops between 9 and 10 months of age. If the infant cries when his mother leaves the room, it might be because he believes she is no longer in the house when he can't see her. If an infant picks up another toy after the one he is playing with rolls under the couch and the infant fails to look for it, he believes the toy that rolled under the couch no longer exists. Patty-cake is a game infants engage in but, it has nothing to do with object permanence. An infant game that does show object permanence is peek-a-boo. In this game, an infant continues to hunt for a hidden face because he believes it is still there.
A mother brings her 1-year-old child to the clinic. The child has no record of previous immunizations, and the mother confirms the child has not been immunized. Teaching by the nurse should include which of the following?
- A. Immunizations may be started at any age.
- B. The recommended immunization schedule must be followed exactly.
- C. If a primary series of immunizations is interrupted, the series must be restarted.
- D. This child is at increased risk for reaction to the vaccines, when they are started.
Correct Answer: A
Rationale: While a recommended immunization schedule exists, immunizations may be started at any age. An interrupted series may be continued and need not be restarted. There is no increased risk for reaction to vaccines due to delay.
A 50 milliliter (ml) bolus of normal saline fluid is ordered by the physician. The physician wants it to infuse in 30 minutes. The nurse should set the pump rate at:
- A. 100 ml per hour for one hour.
- B. 60 ml per hour for one-half hour.
- C. 120 ml per hour for one hour.
- D. 50 ml per hour for one hour.
Correct Answer: A
Rationale: One hundred ml in one hour equals 50 ml in 30 minutes, which is what the physician prescribed. Choice 2 is 10 ml more than the physician prescribed for 30 minutes. Choice 3 is the same as Choice 2; it is 10 ml more than the physician prescribed for 30 minutes. Choice 4 only provides 25 ml over 30 minutes, or half the volume prescribed.
Which of the following motions is identified with the corresponding action? (Action: Turning palm of hand over to face in the anterior direction, dorsum of the hand is pointed downward toward the floor.)
- A. Pronation
- B. Supination
- C. Abduction
- D. Adduction
Correct Answer: B
Rationale: Supination is described as 'Holding a bowl of soup in your hand,' which matches the action of turning the palm to face anteriorly.