Nokea
A client with a head injury has an order for dexamethasone (Decadron) 10 mg IV; push every 6 hours. The dose is available Decadron 4 mg/mL. How much will the nurse administer?
- A. mL(s)
Correct Answer: 2.5 mL
Rationale: Dose: 10 mg ÷ 4 mg/mL = 2.5 mL.
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A client with a history of breast cancer is admitted with complaints of fatigue. The nurse should give priority to:
- A. Monitoring for anemia
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering chemotherapy
Correct Answer: A
Rationale: Fatigue in breast cancer may indicate anemia, a common complication, so monitoring for anemia is the priority.
The client is admitted with a diagnosis of preterm premature rupture of membranes (PPROM). The nurse should prepare to administer which medication?
- A. Magnesium sulfate
- B. Terbutaline
- C. Betamethasone
- D. All of the above
Correct Answer: C
Rationale: Betamethasone is administered in PPROM (24-34 weeks) to enhance fetal lung maturity in anticipation of preterm delivery. Magnesium sulfate may be used for neuroprotection or preeclampsia and terbutaline is a tocolytic but betamethasone is the priority.
The nurse is caring for a client post-colonoscopy. Which finding requires immediate intervention?
- A. Mild abdominal cramping
- B. Bright red blood in the stool
- C. Slight drowsiness
- D. Flatulence
Correct Answer: B
Rationale: Bright red blood in the stool suggests post-colonoscopy bleeding, possibly from perforation, requiring immediate intervention. Cramping (A), drowsiness (C), and flatulence (D) are expected.
A burn victim's immunization history is assessed by the nurse. Which immunization is of priority concern?
- A. Oral poliovirus vaccine
- B. Inactivated poliovirus vaccine
- C. Tetanus toxoid
- D. Hepatitis B vaccine
Correct Answer: C
Rationale: Tetanus toxoid prevents tetanus. Tetanus is transmitted through contaminated wounds.
The nurse is caring for a client with acquired immunodeficiency syndrome. Which finding should be reported to the doctor immediately?
- A. Temperature of 100.2°F
- B. White patches on the tongue
- C. Weight loss of 10 pounds
- D. Respiratory rate of 26 breaths per minute
Correct Answer: D
Rationale: A respiratory rate of 26 breaths per minute suggests respiratory distress, a critical issue in AIDS due to possible opportunistic infections like Pneumocystis pneumonia, requiring immediate reporting.