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A nurse is preparing an IM injection of prednisolone acetate, 30 mg. It is supplied as 50 mg/mL. How many mL should the nurse prepare?
- A. 0.5 mL
- B. 0.7 mL
- C. 0.6 mL
- D. 0.8 mL
Correct Answer: B
Rationale: To calculate the mL needed for the injection, divide the prescribed dose by the concentration of the medication. In this case, 30 mg ÷ 50 mg/mL = 0.6 mL. However, since the nurse should round up to ensure the full dose is administered, the correct answer is 0.7 mL. Choice A is incorrect as it is rounded down. Choice C is incorrect as it is the exact division without rounding up. Choice D is incorrect as it is rounded up too much.
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Toni’s disease process involves a sacral plexus. Assessment should include:
- A. Bladder problems
- B. Bowel management
- C. Sexual activity
- D. . All of the above
Correct Answer: D
Rationale: The correct answer is D: All of the above. Involvement of the sacral plexus can affect bladder control, leading to bladder problems. It can also impact bowel function, requiring bowel management. Additionally, the sacral plexus plays a role in sexual function, so assessment should include sexual activity. Therefore, all options are relevant when assessing a disease process involving the sacral plexus. Other choices are incorrect as they do not cover the comprehensive assessment needed for this specific condition.
Why must a nurse measure the intake and output and recommend a daily fluid intake of approximately 3000 to 4000 mL for a client with pyelonephritis?
- A. To determine the clients response to the therapy
- B. To flush out the infectious microorganisms from the urinary tract
- C. To determine the location of discomfort
- D. To detect any evidence of changes
Correct Answer: B
Rationale: Correct Answer: B
Rationale: Measuring intake and output and recommending increased fluid intake for a client with pyelonephritis is crucial to help flush out infectious microorganisms from the urinary tract. By increasing fluid intake, the client will urinate more frequently, aiding in the removal of bacteria causing the infection. This helps in reducing the bacterial load in the urinary tract and promoting faster recovery. Monitoring intake and output also helps ensure the client is adequately hydrated.
Summary of Other Choices:
A: Monitoring intake and output is more about assessing hydration status and kidney function rather than the response to therapy.
C: Intake and output measurement does not directly determine the location of discomfort in pyelonephritis.
D: Monitoring intake and output is not primarily for detecting changes but for ensuring proper fluid balance and aiding in infection clearance.
The nurse should plan to teach the client with pancytopenia caused by a chemotherapy to;
- A. Begin a program of aggressive, strict mouth care
- B. Avoid traumatic injuries and exposure to any infection
- C. increase oral fluid intake to a minimum of 3000 ml daily
- D. Report any unusual muscle cramps or tingling sensations in the extremities
Correct Answer: B
Rationale: The correct answer is B - Avoid traumatic injuries and exposure to any infection. For a client with pancytopenia caused by chemotherapy, their immune system is compromised, making them more susceptible to infections and bleeding. By avoiding traumatic injuries and exposure to infections, the client can reduce the risk of complications. Option A is incorrect because aggressive mouth care may further damage the already compromised oral mucosa. Option C is incorrect because excessive fluid intake may not be necessary and could worsen electrolyte imbalances. Option D is incorrect because muscle cramps and tingling sensations are not directly related to the main concern of infection and bleeding in pancytopenia.
A client is scheduled for a prostatectomy, and the anesthesiologist plans to use a spinal (sub-arachnoid) block during surgery. In the operating room, the nurse positions the client according to the anesthesiologist’s instructions. Why does the client require special positioning for this type of anesthesia?
- A. To prevent confusion
- B. To prevent cerebrospinal fluid (CSF) leakage
- C. To prevent seizures
- D. To prevent cardiac arrhythmias
Correct Answer: B
Rationale: The correct answer is B: To prevent cerebrospinal fluid (CSF) leakage.
1. Positioning is crucial to prevent CSF leakage as the spinal block is administered into the sub-arachnoid space where CSF is present.
2. Incorrect Answers:
A: Positioning is not related to preventing confusion in this context.
C: Seizures are not typically associated with spinal block anesthesia.
D: Cardiac arrhythmias are not directly impacted by the client's positioning for a spinal block.
Mr. Dela Isla said he cannot comprehend what the nurse was saying. He suffers from:
- A. Insomnia
- B. Agnosia
- C. Aphraxia
- D. Aphasia
Correct Answer: D
Rationale: The correct answer is D: Aphasia. Mr. Dela Isla's inability to comprehend what the nurse was saying indicates a language impairment, which is characteristic of aphasia. Aphasia is a condition that affects a person's ability to understand or produce language due to damage to the brain's language centers. Insomnia (A) is a sleep disorder, Agnosia (B) is a perception disorder, and Apraxia (C) is a motor planning disorder, none of which align with Mr. Dela Isla's symptoms.