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A nurse is caring for a patient who has a prescription for digoxin. Which of the following findings should the nurse report to the provider before administering the medication? Which finding should the nurse report before digoxin?
- A. Heart rate 62/min
- B. Blood pressure 130/80 mm Hg
- C. Potassium level 3.2 mEq/L
- D. Respiratory rate 18/min
Correct Answer: C
Rationale: The correct answer is C: Potassium level 3.2 mEq/L. This finding should be reported to the provider before administering digoxin because hypokalemia can increase the risk of digoxin toxicity. Digoxin and hypokalemia can lead to life-threatening cardiac dysrhythmias. A potassium level below the normal range (3.5-5.0 mEq/L) can potentiate the effects of digoxin on the heart, leading to serious complications.
The other options (A, B, D) are within normal limits and not directly related to the potential interactions with digoxin. Therefore, they do not pose an immediate risk to the patient in the context of digoxin administration. Reporting a potassium level of 3.2 mEq/L is crucial to prevent adverse effects and ensure the safety of the patient.
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A nurse is caring for a client who has nausea and a prescription for metoclopramide intravenously every 8 hours as needed. The client asks the nurse how metoclopramide will relieve her nausea. Which explanation should the nurse provide?How does metoclopramide relieve nausea?
- A. The medication relieves nausea by promoting gastric emptying.
- B. The medication works by relaxing gastric muscles.
- C. The medication works by decreasing gastric acid secretions.
- D. The medication enhances gastric emptying.
Correct Answer: A,D
Rationale: The correct answers are A and D. Metoclopramide relieves nausea by promoting gastric emptying, which helps move food through the stomach faster. This action reduces the feeling of fullness and discomfort, ultimately alleviating nausea. Additionally, enhancing gastric emptying helps prevent reflux, which can contribute to nausea. Choices B and C are incorrect because metoclopramide does not work by relaxing gastric muscles or decreasing gastric acid secretions. These mechanisms do not directly address the issue of delayed gastric emptying, which is the primary reason for nausea relief with metoclopramide.
A nurse is performing tracheostomy care for a patient and plans to remove copious secretions. What actions should the nurse take? What action should the nurse take for tracheostomy suctioning?
- A. Lubricate the suction catheter tip with sterile saline
- B. Hyperventilate the patient on 100% oxygen prior to suctioning
- C. Perform chest physiotherapy prior to suctioning
- D. Suction two to three times with a 60-second pause between passes
Correct Answer: D
Rationale: The correct answer is D: Suction two to three times with a 60-second pause between passes. This is the correct action for tracheostomy suctioning to prevent hypoxia and tissue damage. Suctioning should be limited to 10-15 seconds to minimize the risk of hypoxia. Pausing between passes allows the patient to recover oxygen saturation levels. Choice A is incorrect because lubricating the suction catheter tip with sterile saline is not necessary for tracheostomy suctioning. Choice B is incorrect as hyperventilating the patient on 100% oxygen prior to suctioning can lead to respiratory alkalosis. Choice C is incorrect as performing chest physiotherapy prior to suctioning is not indicated in tracheostomy care.
A nurse is caring for a 3-year-old child who has had 160 mL of urine output over the past 8-hour period. The child weighs 33 lb. Which of the following actions should the nurse take? What should the nurse do for low urine output?
- A. Notify the provider.
- B. Continue to monitor the client.
- C. Perform a bladder scan at the bedside.
- D. Provide oral rehydration fluids.
Correct Answer: B
Rationale: The correct answer is B: Continue to monitor the client. In a 3-year-old child, the average expected urine output is about 1-2 ml/kg/hour. Given the child's weight of 33 lb (approximately 15 kg), the expected urine output over 8 hours would be around 120-240 ml. The child's output of 160 ml falls within this expected range, indicating adequate hydration. Therefore, the nurse should continue monitoring the client for any changes.
Incorrect choices:
A: Notifying the provider is not necessary as the urine output is within the expected range.
C: Performing a bladder scan is not indicated as there is no indication of urinary retention.
D: Providing oral rehydration fluids is not necessary since the child's urine output is adequate.
A nurse is assisting a healthcare provider with a sterile procedure and is preparing to pour solution onto a sterile piece of gauze. In what sequence should the nurse perform the following steps when pouring the sterile solution? In what sequence should the nurse pour sterile solution?
- A. Pick up the bottle with the label facing the palm.
- B. Pour the solution onto the gauze.
- C. Pour 1 to 2 mL into a receptacle.
- D. Perform hand hygiene.
- E. Place the bottle cap face-up on a clean surface.
- F. Remove the bottle cap.
Correct Answer: D,A,F,C,E,B
Rationale: The correct sequence is D, A, F, C, E, B.
1. Perform hand hygiene to ensure cleanliness.
2. Pick up the bottle with the label facing the palm to maintain sterility.
3. Remove the bottle cap to prepare for pouring.
4. Pour 1 to 2 mL into a receptacle to ensure proper amount.
5. Place the bottle cap face-up on a clean surface to prevent contamination.
6. Pour the solution onto the gauze for the sterile procedure to be completed.
Incorrect choices:
- G: It is not a step in the process of pouring sterile solution.
- The correct order ensures sterility, proper amount, and prevention of contamination.
A nurse is preparing to administer amoxicillin 350 mg orally. The available amoxicillin is 250 mg per 5 mL. How many mL should the nurse administer? How many mL of amoxicillin should the nurse administer?
Correct Answer: 7
Rationale: The correct answer is 7 mL. To calculate this, first determine the amount of amoxicillin needed by dividing 350 mg by 250 mg/5 mL to get 7. Then, since 250 mg is in 5 mL, 350 mg is in 7 mL. Other choices are incorrect because they do not accurately calculate the correct dosage based on the given concentration of amoxicillin.