Nokea
A nurse is caring for a client who is scheduled to have surgery. In preparing the client for surgery, which of the following actions is considered outside the nurse’s responsibilities?
- A. Explaining the procedure, risks, and benefits
- B. Reviewing preoperative instructions
- C. Obtaining test results
- D. Ensuring that a signed surgical consent form was completed
- E. Assessing the current health status of the client
Correct Answer: A
Rationale: Explanation:
A nurse explaining the procedure, risks, and benefits of surgery is considered outside their responsibility as this task should be performed by the healthcare provider performing the surgery. Reviewing preoperative instructions, obtaining test results, ensuring a signed surgical consent form, and assessing the client's health status are all within the nurse's responsibilities to ensure the client is prepared for surgery. It is important for the nurse to collaborate with the healthcare provider to ensure accurate information is provided to the client.
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A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?
- A. WBC count
- B. BUN
- C. Potassium
Correct Answer: A
Rationale: The correct answer is A: WBC count. An elevation in WBC count indicates the presence of infection as the body releases more white blood cells to fight off pathogens. In the case of a pressure ulcer, an increased WBC count suggests bacterial invasion and inflammation at the site of the ulcer. BUN (choice B) and Potassium (choice C) are not specific indicators of infection and are more related to kidney function and electrolyte balance, respectively. Therefore, they are not appropriate for determining infection in this context.
A nurse is preparing to administer fluconazole 400 mg by intermittent IV bolus daily. Available is fluconazole 400 mg in 0.9% sodium chloride (NaCl) 200 mL to infuse over 2 hours. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest tenth/whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 100
Rationale: Correct Answer: 100
Rationale: To calculate the IV pump rate, use the formula: (Volume to be infused in mL) / (Time in hours). In this case, 200 mL over 2 hours. 200 / 2 = 100 mL/hr.
Summary:
A. Incorrect. Not the correct calculation for the IV pump rate.
B. Incorrect. Not the correct calculation for the IV pump rate.
C. Incorrect. Not the correct calculation for the IV pump rate.
D. Incorrect. Not the correct calculation for the IV pump rate.
E. Incorrect. Not the correct calculation for the IV pump rate.
F. Incorrect. Not the correct calculation for the IV pump rate.
G. Incorrect. Not the correct calculation for the IV pump rate.
A nurse at a provider’s office is providing teaching to a client who is taking chemotherapy and losing weight. Which of the following should the nurse recommend to increase calorie and protein intake? (Select all that apply)
- A. Add cream to soups.
- B. Dip meats in eggs and bread crumbs before cooking.
- C. Use milk instead of water in recipes.
- D. Top fruits with yogurt.
- E. Increase fluids during meals.
Correct Answer: A,B,C,D
Rationale: The correct answers are A, B, C, and D. Adding cream to soups, dipping meats in eggs and bread crumbs, using milk instead of water in recipes, and topping fruits with yogurt are all effective ways to increase calorie and protein intake for a client undergoing chemotherapy and losing weight. Cream, eggs, bread crumbs, milk, and yogurt are all calorie-dense and protein-rich foods that can help the client meet their nutritional needs. These options provide additional nutrients without adding bulk, making them suitable for someone with a reduced appetite. Choices E, F, and G are incorrect because increasing fluids during meals does not directly address the need for increased calories and protein, and options F and G are not provided in the question.
A nurse is caring for a client following the surgical placement of a colostomy. Which of the following statements indicates the client understands the dietary teaching?
- A. Your largest meal of the day should be in the evening.
- B. Eating yogurt can help decrease the amount of gas that I have.
- C. Carbonated beverages can help control odor.
- D. I should eliminate pasta from my diet so that I don’t have many loose stools.
Correct Answer: B
Rationale: The correct answer is B because eating yogurt can help decrease gas due to its probiotic properties which aid in digestion. This statement shows the client understands dietary adjustments post-colostomy surgery. Choice A is incorrect as meal distribution does not affect colostomy care. Choice C is incorrect as carbonated beverages can worsen odor. Choice D is incorrect as pasta is not necessarily a problematic food post-colostomy.
A nurse is providing discharge teaching to the parent of a child who is prescribed diphenhydramine 25 mg elixir every 4 hours as needed. The amount available is diphenhydramine elixir 12.5 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 2
Rationale: Correct Answer: 2 mL
Rationale: To calculate the mL per dose, divide the prescribed mg by the concentration in mg/mL. 25 mg ÷ 12.5 mg/mL = 2 mL. This dosage ensures the correct amount of diphenhydramine is administered.
Summary of Other Choices:
A: Incorrect, as it does not calculate the dosage correctly.
B-G: Irrelevant as they do not provide any calculations or rationale for the correct dosage.