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A nurse is preparing to administer 0.9% sodium chloride IV infusion 1-L bag at a rate of 200 mL/hr for a client who has rhabdomyolysis. The nurse should expect the IV pump to infuse over how many hours? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 5
Rationale: To calculate the infusion time, divide the total volume (1000 mL) by the rate of infusion (200 mL/hr). This gives 5 hours for the IV pump to infuse the 1-L bag. The correct answer is 5. Other choices are incorrect because they do not result from the correct calculation. Choice A: 2 hours (incorrect, not enough time for the infusion). Choice B: 3 hours (incorrect, not enough time for the infusion). Choice C: 4 hours (incorrect, not enough time for the infusion). Choice D: 6 hours (incorrect, too long for the infusion). Choice E: 7 hours (incorrect, too long for the infusion). Choice F: 8 hours (incorrect, too long for the infusion). Choice G: 9 hours (incorrect, too long for the infusion).
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A nurse is preparing to administer amitriptyline 150 mg PO at bedtime. The amount available is amitriptyline 75 mg tablet. How many tablets should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 2
Rationale: The nurse should administer 2 tablets of amitriptyline 75 mg each to achieve a total dose of 150 mg. Since each tablet is 75 mg, 2 tablets would equal 150 mg. This ensures the patient receives the prescribed dose accurately. Other choices are incorrect because administering 1 tablet would result in only 75 mg, insufficient for the prescribed dose. Administering 3 tablets would exceed the prescribed dose, leading to potential overdose. Choices above 3 tablets are also incorrect as they would significantly exceed the prescribed 150 mg dose, risking adverse effects.
A nurse is assessing a client who is receiving metoprolol. Which of the following indicates a therapeutic effect?
- A. Decreased blood pressure.
- B. Decreased dysrhythmias.
- C. Increased urine output.
- D. Decreased pulse.
Correct Answer: A
Rationale: The correct answer is A: Decreased blood pressure. Metoprolol is a beta-blocker that works by reducing heart rate and decreasing the workload on the heart, leading to a decrease in blood pressure. This is a therapeutic effect as it helps manage conditions like hypertension and angina.
Incorrect choices:
B: Decreased dysrhythmias - While metoprolol can help reduce dysrhythmias, the primary therapeutic effect is on blood pressure.
C: Increased urine output - Metoprolol does not directly affect urine output.
D: Decreased pulse - Decreasing pulse is a common side effect of metoprolol, but the therapeutic effect is primarily on blood pressure.
A nurse working on a medical unit is completing the admission of a client who reports a severe allergy to penicillin. Which of the following actions should the nurse take?
- A. Remove all objects that contain latex from the client’s room.
- B. Verify the client’s medication prescriptions do not include cephalosporin.
- C. Notify dietary services to adjust the client’s diet.
- D. Have the client purchase a medication alert bracelet to wear in the hospital.
Correct Answer: B
Rationale: The correct answer is B: Verify the client’s medication prescriptions do not include cephalosporin. This is essential because cephalosporins are antibiotics that share a similar structure to penicillin and can potentially cause an allergic reaction in individuals with a penicillin allergy. By ensuring that the client's medication prescriptions do not include cephalosporin, the nurse is taking a proactive step to prevent any adverse reactions.
Removing objects containing latex (choice A) is not directly related to the client’s penicillin allergy. Notifying dietary services to adjust the client’s diet (choice C) is unnecessary as the allergy is to penicillin, not food. Having the client purchase a medication alert bracelet (choice D) is not as immediate or essential as verifying medication prescriptions.
A nurse is caring for a client who has benign prostatic hyperplasia (BPH). The nurse should expect which of the following findings?
- A. Painful urination
- B. Urge incontinence
- C. Critically elevated prostate-specific antigen (PSA) level
- D. Difficulty starting the flow of urine
Correct Answer: D
Rationale: The correct answer is D: Difficulty starting the flow of urine. This is an expected finding in a client with benign prostatic hyperplasia (BPH) due to the enlargement of the prostate gland, which can obstruct the urethra and impede the flow of urine. This commonly leads to hesitancy or difficulty initiating urination.
- A: Painful urination is not typically associated with BPH, as it is more commonly seen in conditions like urinary tract infections.
- B: Urge incontinence is not a typical finding in BPH; it is more commonly seen in conditions like overactive bladder.
- C: Critically elevated prostate-specific antigen (PSA) levels are not a direct symptom of BPH but may be used for screening and monitoring prostate cancer.
In summary, difficulty starting the flow of urine is the most relevant finding in BPH due to the mechanical obstruction caused by the enlarged prostate gland.
A nurse is assessing a client who presents to the provider’s office for evaluation of multiple nevi. Which of the following findings should the nurse report to the provider as a possible sign of malignancy?
- A. Intense pruritus
- B. Irregular borders
- C. Uniform pigmentation
- D. Purulent drainage
Correct Answer: B
Rationale: The correct answer is B: Irregular borders. Irregular borders are a classic sign of malignancy in nevi, suggesting potential melanoma. This finding indicates that the nevus may be evolving into a cancerous lesion. It is crucial for the nurse to report this to the provider promptly for further evaluation. Intense pruritus (choice A) is common in benign nevi and not specific to malignancy. Uniform pigmentation (choice C) is typically seen in benign nevi and is not a concerning feature. Purulent drainage (choice D) is more indicative of infection or inflammation rather than malignancy. In summary, irregular borders are a red flag for malignancy, while the other choices are more likely associated with benign nevi or other conditions.