Nokea
A client with a history of a seizure disorder is receiving Phenobarbital. The nurse should teach the client to:
- A. Avoid alcohol
- B. Take the medication with meals
- C. Increase calcium intake
- D. Monitor for weight gain
Correct Answer: A
Rationale: Alcohol can interact with phenobarbital, increasing sedation or reducing seizure control. Meals, calcium, and weight gain are not primary concerns.
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The nurse observes that a client has difficulty chewing and swallowing her food. A nursing response designed to reduce this problem would include:
- A. Ordering a full liquid diet for her
- B. Ordering five small meals for her
- C. Ordering a mechanical soft diet for her
- D. Ordering a puréed diet for her
Correct Answer: C
Rationale: A mechanical soft diet is easier to chew and swallow due to its consistent texture, making it appropriate before trying a puréed diet.
The nurse is caring for a client with a history of a fractured femur who is in a cast. The client complains of swelling. The nurse should:
- A. Apply ice to the cast
- B. Elevate the leg
- C. Massage the leg
- D. Notify the physician immediately
Correct Answer: B
Rationale: Elevating the leg reduces swelling in a casted femur by improving venous return. Ice is helpful, massage is contraindicated, and notification is needed if swelling persists.
Nursing assessment of early evidence of septic shock in children at risk includes:
- A. Fever, tachycardia, and tachypnea
- B. Respiratory distress, cold skin, and pale extremities
- C. Elevated blood pressure, hyperventilation, and thready pulses
- D. Normal pulses, hypotension, and oliguria
Correct Answer: A
Rationale: Fever, tachycardia, and tachypnea are the classic early signs of septic shock in children. Respiratory distress, cold skin, and pale extremities are later signs of septic shock. Elevated blood pressure, hyperventilation, and thready pulses are later signs of septic shock. Normal pulses, hypotension, and oliguria are not early signs of septic shock.
The client is admitted with a diagnosis of preterm labor. Which intervention is most appropriate?
- A. Administer betamethasone
- B. Monitor fetal heart tones
- C. Administer tocolytics
- D. All of the above
Correct Answer: D
Rationale: In preterm labor betamethasone enhances fetal lung maturity tocolytics (e.g. nifedipine) halt contractions and fetal heart tone monitoring assesses fetal well-being. All interventions are appropriate.
The physician has ordered that ampicillin 250 mg IV be given over 30 minutes. The medication is diluted as recommended in 10 mL in the volume control chamber of a set that has a tubing of 12 mL. Which nursing measure is most accurate considering these facts?
- A. Infuse volume at 44 mL/hr.
- B. Infuse volume at 22 mL/hr.
- C. Infuse volume at 10 mL/hr.
- D. Infuse volume at 30 mL/hr.
Correct Answer: A
Rationale: The volume to be infused should be diluted medication volume added to the volume control chamber (10 mL) plus the tubing volume (12 mL). The general formula for calculating IV medications for children is: Rate = Volume to Be Infused X Administration Set Drop Factor (microdrop: 60 gtts/min) / Desired Time to Infuse in Minutes Rate = (10 + 12) 22 × 60 / 30 = 44 mL/hr. (B, C, D) These values are incorrect.