Nokea
A client receives a prescription for dextromethorphan 30 mg every 6 to 8 hours as needed for cough. The bottle is labeled 'Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL'. How many tablespoons should the nurse instruct the client to take within each dose? (Enter numerical value only).
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: A
Rationale: Since the prescription is for 30 mg of dextromethorphan and the bottle is labeled 'Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL', the client should take 15 mL of the suspension per dose. Since there are 15 mL in 1 tablespoon, the client should take 1 tablespoon of the suspension per dose.
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The nurse observes the skin over a client's greater trochanter, as seen in the picture with pressure sores.What actions should the nurse implement?
- A. Instruct the unlicensed assistive personnel to frequently offer oral fluids.
- B. Prepare to implement a pressure redistribution mattress.
- C. Explain to the client that the wound needs debridement.
- D. Obtain hemoglobin of the side to check for anemia and sensitivity.
Correct Answer: B
Rationale: Pressure redistribution is an important part of preventing and treating pressure sores.
Which descriptions of stool warrant additional follow-up by the nurse? (Select all that apply.).
- A. Solid with red streaks.
- B. Formed but solid.
- C. Brown liquid.
- D. Tarry appearance.
- E. Multiple hard pellets.
Correct Answer: A,C,D,E
Rationale: Solid stool with red streaks may indicate lower gastrointestinal bleeding and requires further evaluation. Brown liquid stool may suggest diarrhea or malabsorption issues, warranting further assessment. A tarry appearance can indicate upper gastrointestinal bleeding and requires prompt follow-up. Multiple hard pellets may indicate constipation or dehydration and should be addressed.
The nurse is teaching a client how to do active range of motion (ROM) exercises.To exercise the hinge joints, which action should the nurse instruct the client to perform?
- A. Tap the feet forwards and backwards.
- B. Bend the arm by flexing the ulna to the humerus.
- C. Turn the head to the right and left.
- D. Extend the arm at the side and rotate in circles.
Correct Answer: B
Rationale: To exercise the hinge joints, the nurse should instruct the client to bend the arm by flexing the ulna to the humerus. Hinge joints allow for movement in one direction, like a door hinge. The elbow joint is an example of a hinge joint.
After a long bed rest, a client with a Foley catheter and wrist restraints has repeatedly removed the antibiotic (G) tube and NG tube.At checking the restraints, which action is most important for the nurse to take?
- A. Reinsert the peripheral IV catheter.
- B. Verify that the restraints can be quickly released.
- C. Assess capillary refill distal to the restraints.
- D. Replace the nasogastric tube.
Correct Answer: C
Rationale: When checking the restraints, the most important action for the nurse to take is to assess capillary refill distal to the restraints. This helps to ensure that the restraints are not too tight and that blood flow to the extremities is not compromised.
The charge nurse is assisting a nurse in the admission process for a patient with multiple chronic conditions.Which action taken by the nurse demonstrates a breach of confidentiality to the charge nurse?
- A. Shares the health history with case manager.
- B. Discusses diagnoses with the physical therapist.
- C. Provides a list of food allergies to nutritional services.
- D. Requests military records by phone.
Correct Answer: D
Rationale: Requesting military records by phone without the patient's consent would be a breach of confidentiality.