Nokea
A client who is bleeding after a vaginal delivery receives a prescription for methylergonovine (Methergine) 0.4 mg IM every 2 hours, not to exceed 5 doses. The medication is available in ampules containing 0.2 mg/ml. What is the maximum dosage in mg that the nurse should administer to this client? (Enter numeric value only)
- A. 2
- B. 3
- C. 4
- D. 5
Correct Answer: A
Rationale: To calculate the maximum dosage in mg that the nurse should administer, multiply the dose per administration (0.4 mg) by the maximum number of doses allowed (5 doses): 0.4 mg/dose * 5 doses = 2 mg. Therefore, the nurse should administer a maximum dosage of 2 mg to the client. Choices B, C, and D are incorrect as they do not reflect the correct calculation based on the provided information.
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What information is most important for the nurse to provide to an adolescent female prescribed azithromycin for lower lobe pneumonia and recurrent chlamydia?
- A. Ensure the partner is screened for chlamydia
- B. Report any signs of liver dysfunction immediately
- C. Avoid consuming grapefruit juice while on this medication
- D. Use two forms of contraception while taking this drug
Correct Answer: D
Rationale: The most important information for the nurse to provide to an adolescent female prescribed azithromycin for lower lobe pneumonia and recurrent chlamydia is to use two forms of contraception while taking this drug. Azithromycin can reduce the effectiveness of hormonal contraceptives, increasing the risk of pregnancy. It is crucial to convey this information to prevent unintended pregnancies. Option A is incorrect as the partner should be screened for chlamydia, not HIV, in this case. Option B is not the most important information to provide as liver dysfunction is a rare side effect of azithromycin. Option C is irrelevant as grapefruit juice does not interact with azithromycin. Therefore, the priority information to convey is the importance of using dual contraception to prevent pregnancy.
Following the evacuation of a subdural hematoma, an older adult develops an infection. The client is transferred to the neuro intensive care unit with a temperature of 101.8 F (39.3 C) axillary, pulse of 180 beats/minute, and a blood pressure of 90/60 mmHg. What is the priority intervention to include in this client's plan of care?
- A. Confusion
- B. Check neuro vital signs every 4 hours.
- C. Maintain intravenous access.
- D. Keep the suture line clean and dry.
Correct Answer: C
Rationale: The priority intervention for the client in this scenario is to maintain intravenous (IV) access. Given the client's condition with infection, elevated temperature, tachycardia, and hypotension, it is crucial to ensure IV access for administering antibiotics, fluids, and other medications promptly. This can help manage the infection, stabilize hemodynamics, and support the client's hydration and medication needs. Checking neuro vital signs, although important, is secondary to addressing the immediate need for IV access. Keeping the suture line clean and dry is important for wound care but not the priority when dealing with a systemic infection and hemodynamic instability.
After implementing a new fall prevention protocol on the nursing unit, which action by the nurse-manager best evaluates the protocol's effectiveness?
- A. Compare the number of falls that occurred before and after protocol implementation
- B. Analyze data that reflects the unit's costs incurred due to the new protocol
- C. Conduct a chart review on the unit to determine the number of clients at risk for falling
- D. Consult with the physical therapist to evaluate the benefits of the new fall protocol
Correct Answer: A
Rationale: The best way to evaluate the effectiveness of a new fall prevention protocol is by comparing the number of falls that occurred before and after its implementation. This direct comparison helps in assessing the impact of the protocol on reducing fall rates. Choices B, C, and D do not directly measure the effectiveness of the protocol. Analyzing costs incurred (Choice B), conducting a chart review (Choice C), or consulting with a physical therapist (Choice D) may provide valuable information but do not specifically evaluate the protocol's effectiveness in preventing falls.
After a motor vehicle collision, a client is admitted to the medical unit with acute adrenal insufficiency (Addisonian crisis). Which prescription should the nurse implement?
- A. Determine serum glucose levels
- B. Withhold potassium additives to IV fluids
- C. Give IV corticosteroid replacement
- D. Prepare to initiate IV vasopressors
Correct Answer: C
Rationale: In a client with acute adrenal insufficiency (Addisonian crisis) following a motor vehicle collision, the priority intervention is to administer IV corticosteroid replacement. This is crucial to manage the crisis by replacing the deficient cortisol. Determining serum glucose levels (Choice A) may be important but is not the immediate priority in this situation. Withholding potassium additives to IV fluids (Choice B) is not indicated and may exacerbate electrolyte imbalances. Initiating IV vasopressors (Choice D) is not the primary treatment for acute adrenal insufficiency and should be reserved for managing hypotension that is unresponsive to corticosteroid therapy.
An adult male who admits to abusing IV drugs obtains the results of HIV testing. When informed that the results are positive, he states that he does not want his wife to know. What action should the nurse take?
- A. Tell the client he is required by law to inform his sexual partners of his HIV status
- B. Counsel the client about the importance of notifying his sexual partner
- C. Inform the wife of her health risk related to her husband's HIV results
- D. Report the client's status as a sexually transmitted case to the health department
Correct Answer: B
Rationale: The nurse should counsel the client on the importance of notifying partners about HIV status while respecting confidentiality. Mandatory partner notification laws vary by jurisdiction, so option A cannot be universally applied. Breaching patient confidentiality, as suggested in option C, is unethical. Reporting the client's status to the health department without consent, as in option D, is not appropriate as HIV status is confidential information and is not automatically reported as a sexually transmitted case.