Nokea
The client in the emergency department requires sutures for a laceration on the left leg. Which information is most pertinent prior to suturing the wound?
- A. The client tells the nurse she has never had sutures.
- B. The spouse refuses to leave the room during suturing.
- C. The client shares she is scared of needles.
- D. The client reports hives after having dental surgery.
Correct Answer: D
Rationale: Hives post-dental surgery suggest a possible local anesthetic allergy, critical to know before suturing to avoid anaphylaxis.
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The unlicensed assistive personnel (UAP) reported an intake of 1,000 mL and a urinary output of 1,500 mL for a client who received a thiazide diuretic this morning. Which nursing task could the nurse delegate to the nursing assistant?
- A. Instruct the UAP to restrict the client's fluid intake.
- B. Request the UAP to insert a Foley catheter with an urometer.
- C. Tell the UAP urinary outputs are no longer needed.
- D. Ask the UAP to document fluids on the bedside I & O record.
Correct Answer: D
Rationale: Documenting I&O is within UAP scope; fluid restriction, catheter insertion, or discontinuing monitoring require nursing judgment.
Ringer's lactate is running at 125 mL/hr. The administration set has 15 drops/mL. What should the drip rate be?
- A. 8 drops/min
- B. 31 drops/min
- C. 50 drops/min
- D. 67 drops/min
Correct Answer: B
Rationale: Divide 125 mL/hr by 60 min/hr and multiply by 15 drops/mL: (125 ÷ 60) × 15 = 31.25, rounded to 31 drops/min.
The health care provider orders an IV aminophylline infusion at 30 mg/hr. The pharmacy sends a 1,000 ml bag of D5W containing 500 mg of aminophylline. In order to administer 30 mg per hour, the RN will set the infusion rate at:
- A. 20 ml per hour
- B. 30 ml per hour
- C. 50 ml per hour
- D. 60 ml per hour
Correct Answer: D
Rationale: 60 ml per hour. Using the ratio method to calculate infusion rate: mg to be given (30) : ml to be infused (X) :: mg available (500) : ml of solution (1,000). Solve for X by cross-multiplying: 30 × 1,000 = 500 × X, 30,000 = 500X, X = 30,000 / 500, X = 60 ml per hour.
The female client with Trichomonas vaginalis is prescribed metronidazole (Flagyl), an antibacterial medication. Which statement indicates the client does not understand the discharge teaching?
- A. I will not be able to drink any alcohol while taking this drug.
- B. My boyfriend will need to take this same medication.
- C. I cannot transmit the disease through oral sex.
- D. I must make sure I take all the pills no matter how I feel.
Correct Answer: C
Rationale: Trichomonas can be transmitted via oral sex; this statement shows misunderstanding. Alcohol avoidance, partner treatment, and full course completion are correct.
A client with amyotrophic lateral sclerosis has a percutaneous endoscopic gastrostomy (PEG) tube for the administration of feedings and medications. Which nursing action is appropriate?
- A. Pulverize all medications to a powdery condition
- B. Squeeze the tube before using it to break up stagnant liquids
- C. Cleanse the skin around the tube daily with hydrogen peroxide
- D. Flush adequately with water before and after using the tube
Correct Answer: D
Rationale: Flush adequately with water before and after using the tube. Flushing the tube before and after use not only provides for good tube maintenance, it is flushing that moves medications through. Not all medications should be crushed, for example sustained release preparations should not be cut or pulverized. Stagnant liquids are reduced by flushing after tube use. Cleansing is important, but soap and water are sufficient without the added irritation of hydrogen peroxide.