Nokea
A client with toxic shock has been receiving ceftriaxone sodium (Rocephin), 1 g every 12 hours. In addition to culture and sensitivity studies, which other laboratory findings does the nurse monitor?
- A. Serum creatinine.
- B. Spinal fluid analysis.
- C. Arterial blood gases.
- D. Serum osmolality.
Correct Answer: A
Rationale: Ceftriaxone can cause nephrotoxicity, so the nurse should monitor serum creatinine to assess kidney function. Spinal fluid analysis, arterial blood gases, and serum osmolality are not routinely monitored for ceftriaxone therapy.
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What should the nurse monitor in a client receiving baclofen?
- A. Blood pressure.
- B. Spasticity levels.
- C. Blood glucose.
- D. Respiratory rate.
Correct Answer: B
Rationale: Spasticity levels are monitored to evaluate the effectiveness of baclofen in reducing muscle spasticity.
A nurse is to administer 10 mg of morphine sulfate to a client with three fractured ribs. The available concentration for this drug is 15 mg/mL. How many milliliters should the nurse administer? Round to one decimal point.
Correct Answer: 0.7 mL
Rationale: To calculate: 10 mg ÷ 15 mg/mL = 0.666€¦ mL, rounded to 0.7 mL.
The nurse is to administer midazolam (Versed) 2.5 mg. The medication is available in a 5 mg/mL vial. The nurse should administer ___ mL.
Correct Answer: 0.5
Rationale: To administer 2.5 mg from a 5 mg/mL vial, calculate: 2.5 mg ÷ 5 mg/mL = 0.5 mL. This is a calculation question, not multiple-choice, but included as per instructions.
A client returned home from an overseas tour of duty and tells the nurse he is always tired. He has a temperature of 99.5°F (37.5°C). His skin is dark bronze, and his urine has a dark color. His hemoglobin level is 9 g/dL; his hematocrit is 49, and red blood cells are 2.75 million/µL. What should the nurse do first?
- A. Initiate an intake and output record.
- B. Place the client on bed rest.
- C. Place the client on contact isolation.
- D. Keep the client out of sunlight.
Correct Answer: B
Rationale: The client's symptoms (fatigue, bronze skin, dark urine, low hemoglobin, and RBC count) suggest hemolytic anemia, possibly due to an infectious or toxic exposure overseas. Placing the client on bed rest is the priority to reduce oxygen demand and prevent further hemolysis while diagnostic evaluation proceeds. Intake/output monitoring, isolation, and sunlight avoidance are not immediate priorities.
To prepare the irrigation solution used for removal of cerumen, the nurse should use:
- A. Normal saline.
- B. Sterile water.
- C. Antiseptic solution.
- D. Warm tap water.
Correct Answer: A
Rationale: Normal saline is the preferred solution for ear irrigation, as it is isotonic and safe for the ear canal, minimizing irritation or risk of infection.