Nokea
A nurse is collecting data from a client before administering a hepatitis B immunization. The nurse should withhold the immunization if the client is allergic to which of the following substances?
- A. Baker's yeast
- B. Nuts
- C. Wheat
- D. Egg yolk
Correct Answer: A
Rationale: The correct answer is A: Baker's yeast. Hepatitis B vaccines are produced using baker's yeast, specifically Saccharomyces cerevisiae. If a client is allergic to baker's yeast, there is a risk of an allergic reaction to the vaccine. Nuts (B), wheat (C), and egg yolk (D) are not ingredients used in the hepatitis B vaccine production, so allergies to these substances would not necessitate withholding the immunization.
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A nurse is preparing to administer morphine 0.1 mg/kg IM to a school-age child who weighs 66 lb. What is the dose that the nurse should administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 3
Rationale: The correct answer is 3. To calculate the dose, first convert the child's weight from lb to kg: 1 kg = 2.2 lb, so 66 lb ÷ 2.2 = 30 kg. Then, multiply the weight (30 kg) by the dose (0.1 mg/kg): 30 kg x 0.1 mg/kg = 3 mg. Since the question asks for the dose rounded to the nearest whole number, the nurse should administer 3 mg of morphine.
Choice A, B, C, D, E, F, and G are incorrect because they do not follow the correct calculation process. The correct dose is determined by the weight of the child and the prescribed dosage of 0.1 mg/kg, which yields 3 mg in this case.
History and Physical
Medication Administration Record
Vital Signs
1630:
Called to client's room by emergency call bell. Client is alert and oriented to person, place, and time. Client is short of breath, intercostal retractions visible. Wheezing auscultated throughout lung fields. Diffuse, raised rash present on trunk. Abdomen soft. nontender.
A nurse in the emergency department is assisting in the care of a client.
Click to highlight the findings that require immediate follow-up. To deselect a finding click on the finding again.
Nurses Notes
1630:
Called to client's room by emergency call bell. Client is alert and oriented to person, place, and time. Client is short of breath, intercostal retractions visible. Wheezing auscultated throughout lung fields, Diffuse, raised rash present on trunk. Abdomen soft, nontender
Vital Signs
1630:
Temperature 38.3°C (101°F)
Heart rate 110/min
Respiratory rate 30/min
Blood pressure 90/55 mmHg
Oxygen saturation 91% on room air
Click to highlight the findings that require immediate follow-up.
- A. Client is short of breath
- B. Intercostal retractions visible
- C. Wheezing auscultated throughout lung fields
- D. Diffuse, raised rash present on trunk
- E. Respiratory rate 30/min
- F. Blood pressure 90/55 mmHg
- G. Oxygen saturation 91% on room air
Correct Answer: A,B,C,D,E,F,G
Rationale: [ , , , , , , ]
A nurse is caring for a client who is taking alendronate to treat osteoporosis. The nurse should monitor for which of the following adverse effects?
- A. Drowsiness
- B. Dyskinesia
- C. Musculoskeletal pain
- D. Weight gain
Correct Answer: C
Rationale: The correct answer is C: Musculoskeletal pain. Alendronate is a bisphosphonate used to treat osteoporosis. It can cause musculoskeletal pain as a common adverse effect due to its impact on bone turnover. Monitoring for this adverse effect is essential to ensure patient safety. Drowsiness (A), dyskinesia (B), and weight gain (D) are not typically associated with alendronate use, making them incorrect choices. It is important to focus on the specific pharmacological effects and common adverse reactions of medications to determine the correct answer.
A nurse is reinforcing discharge teaching with a client who has tuberculosis and a prescription for rifampin. Which of the following client statements indicates an understanding of the teaching?
- A. I can discontinue this medication after one negative sputum culture.'
- B. I should take this medication on an empty stomach.'
- C. I should expect to have ringing in my ears.'
- D. I can expect to have joint pain.'
Correct Answer: B
Rationale: The correct answer is B: "I should take this medication on an empty stomach." Rifampin should be taken on an empty stomach to maximize absorption. Taking it with food can decrease its effectiveness. Choice A is incorrect because rifampin treatment typically lasts several months, not just until one negative sputum culture. Choices C and D are incorrect as they are not common side effects of rifampin. The client should be informed about potential side effects, such as gastrointestinal upset or discoloration of bodily fluids, but not ringing in the ears or joint pain.
A nurse is caring for a client who is receiving a continuous IV infusion and reports pain at the IV insertion site. The nurse observes the arm is swollen and cool to touch. After discontinuing the infusion, which of the following actions should the nurse take next?
- A. Restart the infusion in other extremity
- B. Elevate the extremity
- C. Remove the catheter
- D. Apply warm, moist compresses to the site.
Correct Answer: B
Rationale: The correct answer is B: Elevate the extremity. By elevating the extremity, the nurse can help reduce swelling and improve blood flow to the area. This can help alleviate pain and prevent further complications. Removing the catheter (choice C) is necessary but not the immediate next step. Restarting the infusion in another extremity (choice A) can exacerbate the issue. Applying warm, moist compresses (choice D) may not be appropriate if there is swelling. Make sure to monitor the client for any signs of infection or other complications.