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A client is receiving a secondary infusion of erythromycin 1 gram in 100 mL dextrose 5% in water (D5W) to be infused in 45 minutes. How many mL/hour should the nurse program the infusion pump?
- A. 100 mL/hour.
- B. 125 mL/hour.
- C. 133 mL/hour.
- D. 150 mL/hour.
Correct Answer: C
Rationale: To infuse 100 mL in 45 minutes, the infusion rate should be set to 133 mL/hour (100 mL / 0.75 hours). This calculation is obtained by dividing the total volume to be infused by the total time for infusion (100 mL / 0.75 hours = 133 mL/hour). Therefore, choice C is the correct answer. Choices A, B, and D are incorrect because they do not accurately calculate the infusion rate required to deliver the medication within the specified time frame.
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The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding?
- A. Nuchal rigidity
- B. Carotid bruit
- C. Jugular vein distention
- D. Palpable cervical lymph node
Correct Answer: B
Rationale: The correct answer is B: Carotid bruit. A carotid bruit is a significant risk factor for stroke as it indicates turbulent blood flow due to narrowing of the carotid artery. Nuchal rigidity is associated with meningitis, jugular vein distention can be a sign of heart failure, and palpable cervical lymph nodes may indicate infection, but they are not directly linked to stroke risk.
A client with a history of seizures is prescribed phenytoin. Which instruction should the nurse include in the discharge teaching?
- A. Report any signs of a sore throat or fever immediately
- B. Take the medication with antacids to reduce stomach upset
- C. Discontinue the medication if you feel drowsy
- D. Increase the dosage if you experience an aura
Correct Answer: A
Rationale: The correct answer is A: 'Report any signs of a sore throat or fever immediately.' Phenytoin can cause blood dyscrasias, which can manifest as a sore throat or fever. These symptoms could indicate a serious side effect that requires immediate medical attention. Choice B is incorrect because phenytoin should not be taken with antacids as they can decrease its absorption. Choice C is incorrect because discontinuing phenytoin abruptly can lead to rebound seizures; drowsiness is a common side effect that may improve with time. Choice D is incorrect because adjusting the dosage of phenytoin should only be done under healthcare provider supervision, not based on experiencing an aura.
When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain?
- A. Daily weight
- B. Vital signs
- C. Level of consciousness
- D. Bowel sounds
Correct Answer: A
Rationale: Corrected Rationale: Daily weight is the most important assessment to monitor fluid balance in clients with nephrotic syndrome. In nephrotic syndrome, excessive protein loss leads to fluid retention and edema. Monitoring daily weight allows the nurse to assess fluid status accurately. Vital signs, while important, may not directly reflect fluid balance changes in nephrotic syndrome. Level of consciousness and bowel sounds are not typically the primary assessments for monitoring fluid balance in clients with nephrotic syndrome.
A male client with muscular dystrophy fell in his home and is admitted with a right hip fracture. His right foot is cool, with palpable pedal pulses. Lungs are coarse with diminished bibasilar breath sounds. Vital signs are temperature 101 degrees F, heart rate 128 beats/minute, respirations 28 breaths/minute, and blood pressure 122/82. Which intervention is most important for the nurse to implement first?
- A. Obtain oxygen saturation level.
- B. Encourage incentive spirometry.
- C. Assess lower extremity circulation
- D. Administer PRN oral antipyretic.
Correct Answer: D
Rationale: Administering an antipyretic is the most important intervention. The client presents with an elevated temperature, tachycardia, and tachypnea, indicating a fever. Lowering the temperature with an antipyretic is crucial to prevent complications like dehydration, altered mental status, and increased oxygen demand. While assessing lower extremity circulation and oxygen saturation are important, addressing the elevated temperature takes priority in this scenario. Incentive spirometry may be beneficial but is not the priority compared to managing the fever.
A client who had a radical neck dissection returns to the surgical unit with 2 JP drains in the right side of the incision. One JP tube is open and has minimal drainage. Which action should the nurse take to increase drainage into the JP?
- A. Reinforce the incisional dressings and assess behind the neck for drainage.
- B. Place the client in a right lateral side-lying position and elevate the head of the bed.
- C. Irrigate the JP tubing with 1 ml NSS, then close the opening with its tab.
- D. Compress the bulb with the tab open and then reinsert the tab into its opening.
Correct Answer: D
Rationale: Compressing the bulb with the tab open creates suction, which helps increase drainage into the JP drain. This action can aid in removing accumulated fluids from the surgical site. Reinforcing the incisional dressings and assessing behind the neck for drainage (Choice A) is not directly related to increasing drainage into the JP. Placing the client in a right lateral side-lying position and elevating the head of the bed (Choice B) may not directly impact drainage into the JP drain. Irrigating the JP tubing with 1 ml NSS and then closing the opening with its tab (Choice C) is unnecessary and could introduce contaminants into the drain.