Nokea
A client receives a prescription for a secondary infusion of IV erythromycin 1 gram in 200 mL dextrose 5% in water (D5W) to be infused in 90 minutes. The nurse should program the infusion pump to deliver how many mL/hour? (Enter the numerical value only. If rounding is required, round to the nearest whole number.)
Correct Answer: 133
Rationale: Volume = 200 mL, Time = 90 minutes = 1.5 hours. Infusion rate = 200 mL / 1.5 hours = 133.33 mL/hr, rounded to 133 mL/hr.
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A client with a history of chronic obstructive pulmonary disease (COPD) receives a new prescription for an ipratropium inhaler. Which action indicates to the nurse that additional teaching is needed?
- A. Stores the medication at room temperature.
- B. Primes the inhaler with 7 pumps.
- C. Attaches spacer device to the inhaler.
- D. Rinses the mouth after each use.
Correct Answer: B
Rationale: Priming an ipratropium inhaler with 7 pumps is excessive; typically, 2–3 pumps are needed if unused for a period. Room temperature storage, spacer use, and mouth rinsing are correct practices.
Review H and P, nurse's notes, laboratory values, flow sheet, and prescriptions.Click to mark whether the assessment finding represents a therapeutic result of the mannitol administered, a non-therapeutic side effect, or an unrelated finding. Each row must have one option selected.
- A. Peripheral edema: Non-therapeutic side effect
- B. Potassium 2.9: Non-therapeutic side effect
- C. Urine output 280 ml: Therapeutic result
- D. Heart rate 79: Unrelated finding
- E. Intracranial pressure 11mmHg: Therapeutic result
- F. Oxygen saturation: Unrelated finding
Correct Answer:
Rationale: A: Edema is a mannitol side effect. B: Hypokalemia is a side effect. C: Increased urine output is therapeutic. D: Normal heart rate is unrelated. E: Reduced intracranial pressure is therapeutic. F: Normal oxygen saturation is unrelated.
A client with narcolepsy receives a new prescription for methylphenidate. Prior to administration of the medication, the nurse should review the medical record for which condition?
- A. Hypercholesterolemia.
- B. Bronchitis.
- C. Diabetes mellitus.
- D. Hypertension.
Correct Answer: D
Rationale: Methylphenidate, a stimulant, can exacerbate hypertension, requiring careful review of blood pressure history. Hypercholesterolemia, bronchitis, and diabetes are less critical concerns.
An older client with heart failure (HF), coronary artery disease (CAD), and hypertension (HTN), is receiving these daily prescriptions: atenolol, furosemide, and enalapril. Which assessments should the nurse include in evaluating the effectiveness of the medications? (Select all that apply.)
- A. Bowel sounds.
- B. Daily weight.
- C. Heart sounds.
- D. Blood pressure.
- E. Range of motion.
Correct Answer: B,C,D
Rationale: B: Daily weight monitors fluid retention (furosemide effectiveness). C: Heart sounds assess heart failure control (atenolol, enalapril). D: Blood pressure evaluates hypertension management (atenolol, enalapril). Bowel sounds and range of motion are unrelated to these medications’ effects.
The nurse is planning discharge teaching for a client with type 2 diabetes mellitus who has a new prescription for insulin glargine. Which action should the nurse plan to include in the discharge teaching?
- A. Demonstrate how to select dose based on before meal blood sugar readings.
- B. Provide information on increasing medication dosage if ketoacidosis occurs.
- C. Teach the client self-injection skills for daily subcutaneous administration.
- D. Explain to the family how to inject this medication for severe hypoglycemia.
Correct Answer: C
Rationale: Insulin glargine requires daily subcutaneous administration, so teaching self-injection skills is essential. It’s not dosed based on meal readings, adjusted for ketoacidosis, or used for hypoglycemia.