Nokea
A nurse is preparing to administer a 2 mg IV bolus of morphine sulfate. Morphine sulfate is available in a concentration of 10 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: 0.2
Rationale: Calculation: 2 mg ÷ 10 mg/mL = 0.2 mL
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A nurse is caring for a client who has a deep vein thrombosis and is prescribed heparin by continuous IV infusion at 1,200 units/hr. Heparin is available in a concentration of 25,000 units in 500 mL D5W. 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: 24
Rationale: Calculation: (1,200 units/hr ÷ 25,000 units) × 500 mL = 24 mL/hr
A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first?
- A. Administer oxygen therapy
- B. Start an IV infusion of Lactated Ringer's
- C. Initiate cardiac monitoring
- D. Give morphine IV
Correct Answer: A
Rationale: Oxygen is first priority to address hypoxemia caused by PE.
A nurse is assessing a client and discovers the infusion pump with the client's total parenteral nutrition (TPN) solution is not infusing. The nurse should monitor the client for which of the following clinical manifestations?
- A. Fever and chills
- B. Hypertension and crackles
- C. Excessive thirst and urination
- D. Shakiness and diaphoresis
Correct Answer: D
Rationale: These are signs of hypoglycemia from sudden TPN interruption.
A client is being admitted to the emergency department with a possible dissecting abdominal aortic aneurysm. Which of the following clinical manifestations are not signs and symptoms of hypovolemic shock?
- A. Nausea and faintness
- B. Neurologic deficits and apprehension
- C. Hypertension and tachypnea
- D. Diaphoresis and oliguria
Correct Answer: C
Rationale: Hypertension is not typical in hypovolemic shock (hypotension is expected).
A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse that the client is developing this condition?
- A. Anorexia
- B. Weight gain
- C. Distended abdomen
- D. Dyspnea
Correct Answer: D
Rationale: Dyspnea is a hallmark symptom of left-sided heart failure due to pulmonary congestion from blood backing up into the lungs.