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A nurse is assessing a client's circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time?
- A. Femoral
- B. Popliteal
- C. Brachial
- D. Carotid
- F. D
- G. Simultaneous carotid assessment risks reducing cerebral blood flow, posing danger.
Correct Answer:
Rationale: Correct Answer: D: Carotid
Rationale: Assessing the carotid pulse bilaterally simultaneously can compress the carotid arteries, potentially reducing blood flow to the brain and causing harm. It is crucial to assess the carotid pulse one side at a time to prevent any adverse effects on cerebral circulation.
Summary:
A: Femoral - Can be assessed bilaterally.
B: Popliteal - Can be assessed bilaterally.
C: Brachial - Can be assessed bilaterally.
D: Carotid - Should not be assessed bilaterally due to the risk of reducing cerebral blood flow.
E: - Not applicable.
F: D - Incorrect.
G: - Not applicable.
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A baby weighs 10 pounds. How many kg does the baby weigh?
- F. 4.54 kg
- G. Convert 10 lbs by multiplying by 0.45359237 kg/lb: 10 * 0.45359237 = 4.5359237 kg, rounded to 4.54 kg.
Correct Answer:
Rationale: Correct Answer: F: 4.54 kg
Rationale: The correct answer is F because to convert pounds to kilograms, you multiply by the conversion factor 0.45359237 kg/lb. So, 10 lbs * 0.45359237 kg/lb = 4.5359237 kg, rounded to 4.54 kg. This is the accurate conversion from pounds to kilograms.
Summary:
A: The answer is blank.
B: The answer is blank.
C: The answer is blank.
D: The answer is blank.
E: The answer is blank.
G: The calculation in choice G is correct but not rounded correctly, making F the most accurate answer.
1 oz (ounce) = ---------------- mL
- F. 30 mL
- G. 1 fluid ounce is approximately 29.57 mL, rounded to 30 mL for practical use.
Correct Answer:
Rationale: Correct Answer: F: 30 mL
Rationale: 1 fluid ounce is equivalent to approximately 29.57 mL. When rounding for practical use, it is common to round to the nearest whole number, which is 30 mL. This rounding ensures ease of measurement and avoids confusion. Other choices are incorrect as they do not accurately represent the conversion of 1 fluid ounce to milliliters.
Order digoxin (Lanoxin) 0.25 mg IM daily. Available digoxin (Lanoxin) 0.5 mg/2 mL How many mL will the nurse administer?
- F. 1 mL
- G. Proportion: 0.5 mg/2 mL = 0.25 mg/x mL. Cross-multiply: 0.5x = 0.5, x = 1 mL.
Correct Answer:
Rationale: Correct Answer: F: 1 mL
Rationale: The correct answer is 1 mL because to administer 0.25 mg of digoxin (Lanoxin), which is half of the 0.5 mg available in 2 mL, the nurse would need to administer 1 mL. This calculation is based on the proportion method where you set up a proportion (0.5 mg/2 mL = 0.25 mg/x mL) and solve for x. Cross-multiplying gives 0.5x = 0.5, which simplifies to x = 1 mL. Therefore, the nurse will administer 1 mL of digoxin to achieve the prescribed dose of 0.25 mg.
Summary of other choices:
- The other choices are incorrect as they do not follow the correct calculation method or reasoning required to determine the correct volume of medication to administer.
A nurse is performing a mental status examination (MSE) on a client who has a new diagnosis of dementia. Which of the following components should the nurse include?
- A. Grooming
- B. Long-term memory
- C. Support systems
- D. Presence of pain
- E. Affect
- F. A,B,E
- G. Grooming, memory, and affect assess self-care and emotional state, key in dementia. Support systems and pain are separate.
Correct Answer:
Rationale: Correct Answer: F: A, B, E
Rationale:
1. Grooming: Assessing grooming habits helps evaluate the client's ability to perform activities of daily living, which can be affected in dementia.
2. Long-term memory: Testing long-term memory provides insight into the client's cognitive function, a key aspect of dementia evaluation.
3. Affect: Evaluating affect helps determine the client's emotional state and can indicate changes related to dementia progression.
Therefore, including grooming, long-term memory, and affect in the MSE is crucial for assessing self-care abilities, cognitive function, and emotional well-being in a client with dementia.
Summary of other choices:
- Support systems: While important for overall care, assessing support systems is not a direct component of the MSE for dementia evaluation.
- Presence of pain: While assessing pain is important, it is not typically included in a standard MSE for dementia diagnosis.
Lasix 50 mg IV. The available vial contains 80 mg/2 ml. What is the dose in ml?
- F. 1.25 mL
- G. Proportion: 80 mg/2 mL = 50 mg/x mL. Cross-multiply: 80x = 100, x = 1.25 mL.
Correct Answer:
Rationale: Correct Answer: F: 1.25 mL
Rationale: To find the dose in mL, set up a proportion with the available vial concentration and the prescribed dose. Cross-multiply 80 mg/2 mL = 50 mg/x mL to get 80x = 100. Solve for x to find that the dose is 1.25 mL.
Summary:
A, B, C, D, E: These choices do not provide a calculated answer based on the given information.
G: Although the calculation method used is correct, the final answer provided is 1.25 mL, not the setup explanation.