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A nurse is assisting in the care of a client who is to receive a transfusion of packed RBCs. Which of the following actions should the nurse take?
- A. Ensure that the unit of packed RBCs is transfused within 6 hr.
- B. Obtain 0.9% sodium chloride solution for IV infusion.
- C. Use filterless IV tubing for the transfusion.
- D. Remain at the client's bedside for the first 5 min of the transfusion.
Correct Answer: B
Rationale: The correct answer is B because 0.9% sodium chloride solution is the appropriate IV solution to use when administering packed RBCs to prevent hemolysis. The sodium chloride solution is isotonic, which helps maintain the integrity of the RBCs during transfusion. Other choices are incorrect because: A: There is no specific time limit within which packed RBCs must be transfused. C: Using filterless IV tubing can increase the risk of air embolism and contamination. D: Remaining at the client's bedside for only 5 minutes is inadequate for monitoring potential adverse reactions during the transfusion.
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Provider Prescriptions: Tetracycline 500 mg PO twice daily; Vital Signs Initial visit: Temperature 37.1° C (98.8° F), Heart rate 82/min, Blood pressure 118/76 mm Hg, Respiratory rate 16/min, SpO2 99% on room air; Current visit: Temperature 37.5° C (99.5° F), Heart rate 84/min, Blood pressure 122/72 mm Hg, Respiratory rate 18/min, SpO2 99% on room air; History and Physical Initial visit: Client is a 20-year-old female who presents with report of worsening acne over the past few months. Severe inflammatory acne noted over face, neck, and upper back. Client has no significant medical or surgical history. Discussed skin hygiene and use of over-the-counter acne treatments. Current visit: Client reports no improvement in acne since prior visit 2 months ago. Client states they have been gently washing their skin twice daily and using acne treatments as recommended. Client states they are self-conscious and avoids certain social activities. No change in acne noted on assessment. Tetracycline prescribed. Will have the client return to the clinic in 4 weeks.
The nurse should identify that the client is at risk for developing ________and _________
- A. Increased cholesterol level
- B. Gastridium difficite-associated diarrhea
- C. Elevated blood glucose level
- D. Gallstones
- E. Vaginal yeast infection
Correct Answer: B, E
Rationale: Correct Answer: B, E
Rationale:
1. Choice B: Gastridium difficile-associated diarrhea is a risk for clients on antibiotics, disrupting gut flora balance.
2. Choice E: Vaginal yeast infection risk increases with antibiotic use, disrupting vaginal flora.
Summary:
- A, C, D: These choices are not directly related to antibiotic use or disruption of flora balance.
- B, E: Antibiotics can lead to imbalances in gut and vaginal flora, increasing the risk for these conditions.
A nurse is preparing to administer gentamicin to a child who weighs 44 lb. The provider prescribes 6 mg/kg/day IV to be administered in three equal doses. Available is gentamicin 40 mg/mL. How many mL should the nurse administer with each dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 1 mL
Rationale: The correct answer is 1 mL. To calculate the dose for each administration, first convert the child's weight from pounds to kilograms (44 lb = 20 kg). The total daily dose is 6 mg/kg/day, so for a 20 kg child, the total daily dose is 120 mg (6 mg/kg/day x 20 kg). Since it is to be given in three equal doses, each dose would be 40 mg (120 mg total dose ÷ 3 doses). Since the available concentration is 40 mg/mL, the nurse would administer 1 mL for each dose (40 mg ÷ 40 mg/mL = 1 mL). Therefore, the correct answer is 1 mL.
Incorrect answers:
- Choice B: This is incorrect as it does not follow the correct calculation method.
- Choice C: This is incorrect as it does not consider the weight of the child and the total daily dose required.
- Choice D: This is incorrect as it does not
A nurse is reinforcing teaching with a client who has pancreatitis and a new prescription for pancrelipase. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will take this medication whole.
- B. I can expect this medication to cure the pancreatitis.
- C. I should discontinue the medication if I develop fatty stools.
- D. I will take this medication at bedtime.
Correct Answer: A
Rationale: The correct answer is A: "I will take this medication whole." This is correct because pancrelipase should be taken whole to ensure the proper release of enzymes in the small intestine for digestion. Option B is incorrect because pancrelipase does not cure pancreatitis but helps with digestion. Option C is incorrect because fatty stools are expected side effects of pancrelipase and not a reason to discontinue the medication. Option D is incorrect because pancrelipase should be taken with meals or snacks, not specifically at bedtime.
A nurse is caring for a client who reports muscle spasms after receiving haloperidol. Which of the following medications should the nurse expect to administer?
- A. Metoprolol
- B. Benztropine
- C. Oxycodone
- D. Risperidone
Correct Answer: B
Rationale: The correct answer is B: Benztropine. Benztropine is an anticholinergic medication commonly used to treat extrapyramidal symptoms such as muscle spasms caused by antipsychotic drugs like haloperidol. It works by blocking the action of acetylcholine in the brain, helping to alleviate muscle spasms. Metoprolol (A) is a beta-blocker used for hypertension, not muscle spasms. Oxycodone (C) is an opioid for pain relief, not muscle spasms. Risperidone (D) is another antipsychotic but not typically used to treat muscle spasms.
A nurse is caring for a client who has been taking epoetin alfa for 3 months. Which of the following laboratory tests should the nurse monitor to determine the effectiveness of the medication?
- A. Hgb
- B. Troponin
- C. Thyroxine (T4)
- D. Aspartate aminotransferase (AST)
Correct Answer: A
Rationale: The correct answer is A: Hgb. Epoetin alfa is a medication used to treat anemia by stimulating red blood cell production. Monitoring the client's hemoglobin (Hgb) levels is crucial to assess the effectiveness of the medication in increasing red blood cell count. Hemoglobin reflects the oxygen-carrying capacity of the blood and directly correlates with red blood cell levels. Troponin (B), Thyroxine (T4) (C), and Aspartate aminotransferase (AST) (D) are not relevant in monitoring the effectiveness of epoetin alfa therapy as they are related to cardiac function, thyroid function, and liver function, respectively.