A client is prescribed heparin 2,000 units SC q8 hours. The pharmacy sends heparin 5,000 units/mL. How many mL should the nurse administer every 24 hours?
- A. 0.4 mL/day
- B. 0.8 mL/day
- C. 1.2 mL/day
- D. 1.4 mL/day
Correct Answer: C
Rationale: Dose per injection: 2,000 units ÷ 5,000 units/mL = 0.4 mL. Q8 hours = 3 doses/day. 0.4 mL × 3 = 1.2 mL/day.
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Someone sees a nursing assistant yell at an elderly client and throw his lunch tray off the table. The nursing assistant could likely be charged with
- A. negligence.
- B. assault.
- C. malpractice.
- D. battery.
Correct Answer: B
Rationale: Yelling and throwing a tray constitute assault (threatening behavior causing fear of harm). Battery involves physical contact, negligence involves failure to act, and malpractice applies to professional errors.
The nurse is teaching a group of new graduates about the safety needs of the client receiving chemotherapy. Before administering chemotherapy, the nurse should:
- A. Administer a bolus of IV fluid
- B. Administer pain medication
- C. Administer an antiemetic
- D. Allow the patient a chance to eat
Correct Answer: C
Rationale: Administering an antiemetic before chemotherapy prevents nausea and vomiting, common side effects of these drugs.
The nurse is teaching a client with a new diagnosis of atrial fibrillation about warfarin (Coumadin) therapy. Which of the following statements by the client indicates a need for further teaching?
- A. I will avoid eating large amounts of spinach.
- B. I will report any signs of bleeding to my doctor.
- C. I will take my medication at the same time each day.
- D. I will stop taking the medication if I feel dizzy.
Correct Answer: D
Rationale: warfarin should not be stopped without medical advice, as it increases the risk of clotting
A client with recurrent episodes of gout has been advised to eat a low-purine diet. Which of the following foods should the nurse advise him to limit or avoid? Select all that apply.
- A. Liver.
- B. Sardines.
- C. Wine.
- D. Low-fat yogurt.
- E. Beef broth.
- F. Potatoes.
Correct Answer: A,B,E
Rationale: High-purine foods like liver (A), sardines (B), and beef broth (E) should be limited to reduce gout flare-ups. Wine (C), low-fat yogurt (D), and potatoes (F) are low in purines and generally safe.
Which of the following findings are indicative of peripheral arterial insufficiency? Select all that apply.
- A. Throbbing, cramping pain that increases with exercise.
- B. Aching pain that increases with dependency.
- C. Capillary refill time of less than two seconds.
- D. Shiny skin with decreased hair.
- E. Brown pigment about the ankles and lower legs.
- F. Pale color on elevation and redness on dependency.
Correct Answer: A,D,F
Rationale: Peripheral arterial insufficiency causes throbbing pain with exercise (A), shiny skin with hair loss (D), and pale color on elevation with redness on dependency (F). Aching pain with dependency (B) and brown pigment (E) suggest venous insufficiency, and capillary refill <2 seconds (C) is normal.
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