Nokea
A nurse is caring for a client with diabetes mellitus who is prescribed regular insulin via a sliding scale. After administering the correct dose at 0715, the nurse should ensure the client receives breakfast at which of the following times?
- A. 730
- B. 745
- C. 815
- D. 720
Correct Answer: A
Rationale: The correct answer is A: 730. After administering regular insulin, it is crucial to ensure the client receives breakfast within 30 minutes to an hour to prevent hypoglycemia. Breakfast at 730 allows adequate time for the insulin to start working before the client consumes food. Choice B (745) is too late, increasing the risk of hypoglycemia. Choice C (815) is too delayed and may cause an imbalance in blood sugar levels. Choice D (720) is too soon after administering insulin, increasing the risk of hypoglycemia.
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A nurse on a pediatric unit is reviewing her client assignment following the shift report. Which of the following clients should the nurse plan to assess first?
- A. An infant who has pertussis and is receiving oxygen via nasal cannula.
- B. A school-age child who has diabetes mellitus and requires blood glucose monitoring.
- C. An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions.
- D. A toddler who has both arms in casts and needs to be fed his breakfast.
Correct Answer: A
Rationale: The correct answer is A. The nurse should assess the infant with pertussis receiving oxygen first because pertussis can cause respiratory distress. Assessing the oxygenation status is a priority to ensure the infant is receiving adequate oxygenation. This can prevent potential complications such as respiratory failure. The other clients have important needs but do not have immediate life-threatening conditions requiring urgent assessment. The school-age child with diabetes requires monitoring but can wait a little longer. The adolescent in sickle cell crisis ready for discharge instructions can be assessed after ensuring the infant's immediate needs are addressed. The toddler with both arms in casts needing feeding can also wait since feeding can be done after the infant's urgent assessment.
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.
A nurse is reviewing the medical record of a client who reports drinking three to four glasses of wine each night and taking 3,000 mg of acetaminophen daily. Which of the following laboratory values is the priority for the nurse to assess?
- A. Creatinine
- B. Aspartate aminotransferase (AST)
- C. Amylase
- D. Antidiuretic hormone (ADH)
Correct Answer: B
Rationale: The correct answer is B: Aspartate aminotransferase (AST). The nurse should prioritize assessing AST because both alcohol consumption and acetaminophen use can lead to liver damage. Elevated AST levels indicate liver injury, making it crucial to monitor for potential hepatotoxicity in this client. Creatinine (choice A) is typically assessed to evaluate kidney function, not directly related to alcohol or acetaminophen use. Amylase (choice C) is an enzyme related to pancreas health, not specifically affected by alcohol or acetaminophen. Antidiuretic hormone (ADH - choice D) is related to fluid balance, not a priority in this scenario. By focusing on AST, the nurse can promptly identify any liver damage and intervene accordingly.
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 is caring for a client who is postpartum and asks the nurse when her breast milk will 'come in.' Which of the following responses should the nurse make?
- A. Within 2 days.
- B. In 3 to 5 days.
- C. In about 10 days.
- D. In 6 to 8 days.
Correct Answer: B
Rationale: The correct answer is B: In 3 to 5 days. This is because breast milk typically comes in around 3 to 5 days after giving birth, as it takes time for hormonal changes to trigger milk production. Option A (Within 2 days) is too soon for most women to experience lactogenesis II. Option C (In about 10 days) and Option D (In 6 to 8 days) are both incorrect as they are outside the typical timeframe for milk production to start. It's important for the nurse to provide accurate information to the client to manage her expectations and provide proper support during this crucial time.