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. Add 0.5 mL of diluent to the medication.
- B. Inject air into the ampule prior to drawing the medication into a syringe.
- C. Use a filter needle to aspirate the medication.
- D. Cleanse the tip of the ampule with an alcohol swab after opening.
Correct Answer: C
Rationale: A filter needle prevents glass particles from being drawn into the syringe from the ampule.
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A nurse is reinforcing teaching with a group of newly licensed nurses regarding client confidentiality. In which of the following situations can the nurse disclose health information without the client's written consent?
- A. To an insurance agency in regard to a life insurance policy
- B. To a family member when the client is not available
- C. To a medical interpreter service on behalf of a client
- D. To an employer for a pre-employment screening
Correct Answer: C
Rationale: Disclosure to an interpreter is allowed to facilitate care, adhering to HIPAA exceptions.
A nurse is reinforcing teaching about seizure management with the family of a client who has a seizure disorder. Which of the following statements by a family member indicates an understanding of the teaching?
- A. I will gently restrain him during seizures.
- B. I will loosen his clothing during seizures.
- C. I will insert a washcloth in his mouth during seizures.
- D. I will turn him on his back during seizures.
Correct Answer: B
Rationale: Loosening clothing ensures airway safety and comfort during a seizure.
A nurse is reviewing the medical record of a client. Click to highlight below the findings that require immediate follow-up.
- A. Neurological: Alert and oriented to person, place, and time; deep tendon reflexes 4+
- B. Musculoskeletal: Generalized weakness with equal bilateral muscle strength and mild leg cramping
- C. Respiratory: Lungs clear
- D. Cardiovascular: Heart rate irregular, Heart rate 95/min
- E. Gastrointestinal: Bowel sounds hyperactive x 4 quadrants
Correct Answer: D
Rationale: An irregular heart rate (D) requires immediate follow-up due to potential arrhythmia risks.
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?
- A. 12.5 mL (calculated: 55 lb = 25 kg, 50 mg/kg = 1250 mg/day, 1250 mg / 4 doses = 312.5 mg/dose, 312.5 mg / 125 mg/5 mL = 12.5 mL)
Correct Answer: A
Rationale: Calculation confirms 12.5 mL per dose is correct.
A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps?
- A. Unlock and remove the inner cannula.
- B. Scrub the inside and outside of the inner cannula with a small brush
- C. Wipe the inside of the inner cannula with a folded pipe cleaner.
- D. Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin.
- E. Cleanse the stoma site with 0.9% sodium chloride solution.
Correct Answer: A, D, B, C, E
Rationale: Sequence ensures sterile preparation and cleaning: remove cannula, prepare solution, scrub, wipe, cleanse stoma.