Nokea
The nurse is preparing to administer phenytoin (Dilantin), 100 mg intravenous push, to the client with a head injury who has an IV of D5W at 50 mL/hr. Which intervention should the nurse implement?
- A. Flush the IV tubing before and after with normal saline.
- B. Administer the medication if the Dilantin level is 22 mcg/mL.
- C. Push the Dilantin intravenously slowly over five (5) minutes.
- D. Expect the intravenous tubing to turn cloudy when infusing medication.
Correct Answer: A
Rationale: Phenytoin is incompatible with D5W; saline flush prevents precipitation. Level of 22 mcg/mL is toxic, slow push is correct but not primary, and cloudiness is avoidable.
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An 80 year-old client is admitted with a diagnosis of malnutrition. In addition to physical assessments, which of the following lab tests should be closely monitored?
- A. Urine protein
- B. Urine creatinine
- C. Serum calcium
- D. Serum albumin
Correct Answer: D
Rationale: Serum albumin. Serum albumin is a valuable indicator of protein deficiency and, later, nutritional status in adults. A normal reading for an elder's serum albumin is between 3.0-5.0 g/dl.
The nurse is caring for a 10 year-old client who will be placed on heparin therapy. Which assessment is critical for the nurse to make before initiating therapy?
- A. Vital signs
- B. Weight
- C. Lung sounds
- D. Skin turgor
Correct Answer: B
Rationale: Weight. Check the client's weight because dosage is calculated on the basis of weight.
The male client comes to the emergency department and reports he stepped on a rusty nail at home about two (2) hours ago. Which question would be most important for the nurse to ask during the admission assessment?
- A. What have you used to clean the puncture site?
- B. Did you bring the nail with you so we can culture it?
- C. Do you remember when you had your last tetanus shot?
- D. Are you able to put any weight on your foot?
Correct Answer: C
Rationale: Tetanus risk is high with puncture wounds; knowing the last tetanus shot guides prophylaxis, the priority per CDC guidelines.
A woman who is taking cortisone for an acute exacerbation of rheumatoid arthritis is upset about the fat face she has developed. She says to the nurse, 'I'm going to quit taking that cortisone.' The nurse's response should be based on which understanding?
- A. Cortisone does not cause a fat face.
- B. The symptoms will lessen as her body adjusts to the medication.
- C. The drug should be immediately discontinued when adverse effects occur.
- D. Cortisone should never be abruptly discontinued.
Correct Answer: D
Rationale: Abrupt discontinuation of cortisone can cause adrenal insufficiency; tapering is required to prevent complications.
An adult client is seen in the clinic, and sulfisoxazole (Gantrisin) is prescribed. Which information is most appropriate for the nurse to include in the teaching?
- A. Limit your fluid intake to four glasses a day.
- B. If it upsets your stomach, try taking it with an antacid.
- C. Avoid going out in the sun while taking this drug.
- D. Take the tablets with orange juice or milk.
Correct Answer: C
Rationale: Sulfisoxazole causes photosensitivity; avoiding sun exposure is critical to prevent skin reactions.