Nokea
A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?
- A. Use a filter needle to aspirate the medication.
- B. Inject air into the ampule prior to drawing the medication into a syringe.
- C. Cleanse the tip of the ampule with an alcohol swab after opening.
- D. Add 0.5 mL of diluent to the medication.
Correct Answer: A
Rationale: A filter needle prevents glass particles from entering the syringe.
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A nurse is caring for a client who has a new prescription for a belt restraint. Which of the following actions should the nurse take?
- A. Apply the belt restraint over the client's gown.
- B. Tie the belt restraint to the side rail of the bed.
- C. Check the client's skin integrity every 4 hr.
- D. Make sure four fingers fit between the restraint and the client's body.
Correct Answer: A
Rationale: Applying the restraint over the gown protects skin and ensures comfort.
A nurse is preparing to administer ampicillin to a school-age child who weighs 55 lb. The provider prescribes 50 mg/kg/day in 4 equal doses. Available is ampicillin oral suspension 125 mg/5 mL. How many mL should the nurse administer with each dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 12.5 mL
Rationale: 55 lb = 25 kg; 50 mg/kg/day = 1250 mg/day; 1250 mg / 4 doses = 312.5 mg/dose; 312.5 mg / (125 mg/5 mL) = 12.5 mL/dose.
A nurse is providing end-of-life care to a client who is experiencing dyspnea. Which of the following actions should the nurse take?
- A. Provide oral care to the client once every 8 hr.
- B. Use a fan to circulate air in the client's room.
- C. Reposition the client once every 4 hr.
- D. Place the head of the client's bed flat.
Correct Answer: B
Rationale: A fan circulates air, relieving dyspnea by enhancing the feeling of airflow.
A nurse is preparing to obtain a capillary blood specimen from a client. Which of the following actions should the nurse take? (Select all that apply.)
- A. Squeeze the client's finger until a blood drop forms.
- B. Prick the side of the client's finger.
- C. Elevate the client's hand above the level of the heart.
- D. Cleanse the client's finger with an iodine swab.
- E. Apply clean gloves.
Correct Answer: B,E
Rationale: B: Pricking the side is less painful and safer. E: Gloves prevent contamination and ensure safety.
A nurse in a provider's office is reviewing data from a client's medical record. Which of the following findings should the nurse identify as a risk factor for cardiovascular disease?
- A. Orthostatic hypotension
- B. Type 1 diabetes mellitus
- C. Family history of osteoporosis
- D. BMI of 24
Correct Answer: B
Rationale: Type 1 diabetes increases cardiovascular risk due to chronic hyperglycemia damaging blood vessels.