Nokea
A client was to receive 1 g of vancomycin intravenously in 200 mL of iso-osmotic solution over 60 minutes per infusion pump. However, the IV administration was discontinued after 45 minutes because the client developed nausea and chills. How many milligrams of vancomycin did the client receive? Record your answer using a whole number.
Correct Answer: 750
Rationale: 1 g = 1000 mg in 200 mL over 60 min. In 45 min, 45/60 = 0.75 of dose = 0.75 X 1000 = 750 mg.
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A client with diabetes asks the nurse for advice regarding methods of birth control. Which method of birth control is most suitable for the client with diabetes?
- A. Intrauterine device
- B. Oral contraceptives
- C. Diaphragm
- D. Contraceptive sponge
Correct Answer: C
Rationale: The diaphragm is suitable for diabetic clients as it avoids hormonal effects that could impact glucose control.
An 8-year-old client is returned to the recovery room after a bronchoscopy. The nurse should position the client
- A. in semi-Fowler’s position.
- B. prone, with the head turned to the side.
- C. with the head of the bed elevated 45° and the neck extended.
- D. supine, with the head in the midline position.
Correct Answer: A
Rationale: check vital signs every 15 minutes until stable, assess for respiratory difficulty (stridor and dyspnea resulting from laryngeal edema or laryngospasm)
A client scheduled for a carotid endarterectomy requires insertion of an intra-arterial blood pressure-monitoring device. The nurse plans to perform the Allen test. Which observation indicates patency of the ulnar artery?
- A. Blanching of the hand on compression and release of the ulnar artery
- B. Muscular twitching of the bicep muscle with use of a tourniquet at the wrist
- C. Hand turning pink after the nurse releases the pressure on the ulnar artery
- D. Flexion of the wrist when tapping the ulnar artery with a reflex hammer
Correct Answer: C
Rationale: The Allen test assesses collateral circulation. The hand turning pink after releasing ulnar artery pressure indicates patency, ensuring adequate blood flow if the radial artery is cannulated.
The nurse is caring for a client scheduled for a surgical repair of an abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period?
- A. Assessment of the client's level of anxiety
- B. Evaluation of the client's exercise tolerance
- C. Identification of peripheral pulses
- D. Assessment of bowel sounds and activity
Correct Answer: C
Rationale: Identifying peripheral pulses is critical to establish a baseline for vascular status, as an abdominal aortic aneurysm repair can affect blood flow to the extremities, and postoperative complications may include vascular occlusion.
The nurse is caring for a client after a motor vehicle accident. The client has a fractured tibia, and bone is noted protruding through the skin. Which action is of priority?
- A. Provide manual traction above and below the leg
- B. Cover the bone area with a sterile dressing
- C. Apply an ACE bandage around the entire lower limb
- D. Place the client in the prone position
Correct Answer: B
Rationale: An open fracture with protruding bone risks infection. Covering with a sterile dressing is the priority to prevent contamination. Traction or bandaging may worsen the injury.