Nokea
A 36-month-old child weighing 44 lb is to receive ceftriaxone (Rocephin) 2 g I.V. every 12 hours. The recommended dose of Rocephin is 50 to 75 mg/kg/day in divided doses. The nurse should:
- A. Administer the medication as ordered.
- B. Administer half the ordered dose.
- C. Call the laboratory to check the therapeutic serum level of Rocephin.
- D. Withhold administering the Rocephin and notify the child's physician.
Correct Answer: D
Rationale: 44 lb = 20 kg. Recommended dose: 50-75 mg/kg/day = 1000-1500 mg/day. 2 g (2000 mg) every 12 hours = 4000 mg/day, exceeding the safe dose, so the nurse should notify the physician.
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Assessment of a nulligravid client in active labor reveals the following: complaints of moderate discomfort; cervix dilated $3 \mathrm{~cm}, 0$ station and completely effaced; fetal heart rate of $136 \mathrm{bpm}$. Which of the following should the nurse plan to do next?
- A. Assist the client with comfort measures and breathing techniques.
- B. Turn the client from the left side-lying position to the right side-lying position.
- C. Prepare the client for epidural anesthesia to relieve pain.
- D. Instruct the client that internal fetal monitoring is necessary.
Correct Answer: A
Rationale: Moderate discomfort in early labor is managed with non-pharmacologic comfort measures and breathing techniques to promote coping.
The first thing that you should do immediately after a client accident is to:
- A. Notify the doctor.
- B. Render care.
- C. Assess the client.
- D. Notify the nurse manager.
Correct Answer: C
Rationale: The first action after a client accident is to assess the client to determine the extent of injury and immediate needs, following the nursing process.
The nurse is caring for a client with a chest tube in place for a pneumothorax. Which of the following findings indicates that the chest tube is functioning properly?
- A. Continuous bubbling in the water seal chamber.
- B. Absence of tidaling in the water seal chamber.
- C. Fluctuation of fluid in the drainage tube with respiration.
- D. No drainage in the collection chamber.
Correct Answer: C
Rationale: Fluctuation (tidaling) in the drainage tube with respiration indicates the chest tube is patent and functioning to remove air or fluid.
The nurse is caring for a client with a history of deep vein thrombosis (DVT). Which of the following laboratory values should the nurse monitor?
- A. Activated partial thromboplastin time (aPTT).
- B. Prothrombin time (PT).
- C. International normalized ratio (INR).
- D. D-dimer.
Correct Answer: A, D
Rationale: aPTT monitors heparin therapy, and D-dimer indicates clot presence in DVT.
The client with borderline personality disorder spends much time around the nurse's station, making numerous minor requests. The nurse interprets these behaviors as indicating which of the following?
- A. Fears of abandonment and attention seeking
- B. Enjoyment of bothering the staff
- C. Boredom suggesting the need for something to do
- D. Lack of desire for involvement in milieu activities
Correct Answer: A
Rationale: Frequent requests and presence at the nurse's station in borderline personality disorder often reflect fears of abandonment and attention-seeking behaviors, characteristic of the disorder.