Nokea
A nurse is preparing to administer acetaminophen 10 mg/kg PO every 6 hr to a toddler who weighs 26.4 lb. Available is acetaminophen 80 mg/0.8 mL liquid. 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.)
- A. 1.2
Correct Answer: A
Rationale: To calculate the correct dose, first convert the toddler's weight from pounds to kilograms: 26.4 lb / 2.2 = 12 kg. Then calculate the dose: 10 mg/kg * 12 kg = 120 mg per dose. Next, determine how many mL of the liquid acetaminophen contain 120 mg: 80 mg/0.8 mL = 120 mg/X mL. Cross multiply to find X = 1.2 mL. Therefore, the correct answer is A: 1.2 mL. Other choices are incorrect as they do not align with the calculated dose based on the toddler's weight and the concentration of the liquid form of acetaminophen available.
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A nurse is collecting data from a client who has been taking carbamazepine. Which of the following is an adverse effect of carbamazepine and should be reported to the provider?
- A. Sore throat
- B. Increased salivation
- C. Urge incontinence
- D. Gingivitis
Correct Answer: A
Rationale: The correct answer is A: Sore throat. Carbamazepine can cause agranulocytosis, a serious condition characterized by a decrease in white blood cells, leading to symptoms like sore throat. This is a potentially life-threatening adverse effect that should be reported to the provider immediately. Increased salivation (choice B), urge incontinence (choice C), and gingivitis (choice D) are not common adverse effects of carbamazepine and do not require immediate reporting.
Vital Signs
Laboratory Results
0800:
Client is admitted with a 3-day history of abdominal cramps and diarrhea of 4 to 5 liquid stools per day.
Client was taking amoxicillin/clavulanate 875 mg PO every 12 hr for 10 days for a respiratory tract infection. Antibiotics completed 7 days ago.
Bilateral breath sounds clear and present throughout.
Abdomen soft, distended with hyperactive bowel sounds audible in all 4 quadrants.
Stool is watery and contains mucous. Stool sent for culture.
The nurse should first address the client's ___ followed by the client's ___. (Options: Hgb level, Blood pressure, temperature, Hct level, abdominal findings, potassium level)
- A. Hgb level
- B. Blood pressure
- C. temperature
- D. Hct level
- E. abdominal findings
- F. potassium level
Correct Answer: B,F
Rationale: Action to Take: B, F; Potential Condition: Hypovolemia; Parameter to Monitor: Blood Pressure, Potassium Level.
Rationale:
1. Blood pressure should be addressed first to assess perfusion status and hemodynamic stability.
2. Potassium level should be monitored next due to potential electrolyte imbalances in hypovolemia.
3. Hgb, Hct, and abdominal findings are important but secondary to addressing perfusion and electrolyte balance.
4. Temperature is not typically the initial concern in hypovolemia.
A nurse is caring for a client who is taking allopurinol. Which of the following laboratory findings indicates the medication has been effective?
- A. Decreased triglycerides
- B. Decreased uric acid
- C. Increased albumin
- D. Increased potassium
Correct Answer: B
Rationale: The correct answer is B: Decreased uric acid. Allopurinol is used to treat high levels of uric acid in the blood, which can lead to conditions like gout. A decrease in uric acid levels indicates that the medication is effectively lowering the client's uric acid levels. Triglycerides (choice A) are not directly affected by allopurinol. Albumin (choice C) and potassium (choice D) levels are not typically influenced by allopurinol therapy.
A nurse is reinforcing discharge teaching with a client who has a prescription for rifampin for the treatment of tuberculosis (TB). Which of the following instructions should the nurse include in the teaching?
- A. Take the medication on an empty stomach.
- B. Discontinue the medication if your saliva turns orange.
- C. Return for another TB skin test in 3 months.
- D. You will need to take this medication for 1 week.
Correct Answer: A
Rationale: The correct answer is A: Take the medication on an empty stomach. Rifampin is best absorbed when taken on an empty stomach, usually 1 hour before or 2 hours after meals. This maximizes its effectiveness in treating TB. Choice B is incorrect because discoloration of body fluids (including saliva) is a known side effect of rifampin and does not indicate the need to discontinue the medication. Choice C is incorrect because the client should not return for another TB skin test in 3 months unless specifically instructed by the healthcare provider. Choice D is incorrect because treatment for TB usually lasts for several months, not just 1 week.
A nurse is administering the first dose of ramipril to a client who has hypertension. The client reports feeling dizzy and lightheaded. Which of the following should the nurse administer?
- A. 15 g of carbohydrates
- B. Naloxone
- C. Diphenhydramine
- D. Fluid bolus
Correct Answer: D
Rationale: The correct answer is D: Fluid bolus. The client is experiencing symptoms of hypotension, a common side effect of ramipril. Administering a fluid bolus helps increase blood volume, improving blood pressure and alleviating dizziness and lightheadedness. It is important to address the underlying cause of the symptoms. Choices A, B, and C are not appropriate in this situation as they do not address the hypotension caused by ramipril. Administering carbohydrates (A) is irrelevant, naloxone (B) is used for opioid overdose, and diphenhydramine (C) is an antihistamine and not indicated for hypotension.