Nokea
A client with multiple sclerosis has an order to receive Solu Medrol 200mg IV push. The available dose is Solu Medrol 250 mg per mL. How many mL should the nurse administer?
Correct Answer: 0.8
Rationale: Dose: 200 mg ÷ 250 mg/mL = 0.8 mL. The nurse should administer 0.8 mL.
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A client with increased intracranial pressure is receiving Osmitrol (Mannitol) and Furosemide (Lasix). The nurse recognizes that these two drugs are given to reverse which effect?
- A. Energy failure
- B. Excessive intracellular calcium
- C. Cellular edema
- D. Excessive glutamate release
Correct Answer: C
Rationale: Mannitol and Furosemide reduce cellular edema by promoting diuresis and osmotic fluid shifts, lowering ICP. Energy failure (A), calcium (B), and glutamate (D) are not directly targeted.
The client is admitted with a diagnosis of bacterial meningitis. Which precaution should the nurse implement?
- A. Standard precautions
- B. Droplet precautions
- C. Contact precautions
- D. Airborne precautions
Correct Answer: B
Rationale: Bacterial meningitis (e.g., Neisseria meningitidis) is transmitted via respiratory droplets, requiring droplet precautions. Standard, contact, and airborne precautions are not appropriate.
An elderly client refuses to take her daily medication for hypertension. Which action should the nurse take at this time?
- A. Administer the medication by injection
- B. Obtain help administering the medication
- C. Skip the dose of medication and attempt to give it later
- D. Explore the reason for the client’s refusal to take the medication
Correct Answer: D
Rationale: Exploring the reason for the client’s refusal respects autonomy and may reveal misunderstandings, fears, or side effects that can be addressed. Administering by injection or with help violates autonomy, and skipping the dose delays treatment without addressing the issue.
The nurse is caring for a client with a diagnosis of oligohydramnios. Which finding is most likely to be present?
- A. Decreased fetal movement
- B. Increased fetal heart rate
- C. Uterine size larger than expected
- D. Fetal macrosomia
Correct Answer: A
Rationale: Oligohydramnios (low amniotic fluid) can restrict fetal movement due to limited space making decreased fetal movement a likely finding. Fetal heart rate may be normal or show distress uterine size is smaller and macrosomia is unrelated.
In preparation for the removal of the client's chest tubes, the nurse should instruct the client to:
- A. Breathe normally
- B. Hold his breath and bear down
- C. Take deep breaths
- D. Take shallow breaths
Correct Answer: B
Rationale: During chest tube removal, the client should hold their breath and bear down (Valsalva maneuver) to increase intrathoracic pressure, reducing the risk of air entering the pleural space.