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; 25 kg × 50 mg/kg/day = 1250 mg/day; 1250 mg ÷ 4 = 312.5 mg/dose; 312.5 mg ÷ (125 mg/5 mL) = 12.5 mL.
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A nurse is collecting data about cranial nerve function from an adult client. Which of the following images depicts the method the nurse should use to check the function of the hypoglossal cranial nerve (XII)?
- A. Image A
- B. Image B
- C. Image C
- D. Image D
Correct Answer: A
Rationale: Image A shows tongue deviation testing, specific to hypoglossal nerve (XII) function.
A nurse is caring for a client and observes a nurse from another unit reviewing the client's medical record. Which of the following actions should the nurse take?
- A. Complete an incident report about the breach of confidentiality.
- B. Tell the nurse that permission from the risk manager is required to view the client's record.
- C. Remind the nurse that only staff caring for the client may access the client's record.
- D. Contact facility security to remove the nurse from the unit.
Correct Answer: C
Rationale: Reminding about access protocol directly addresses unauthorized viewing, maintaining confidentiality per HIPAA.
A nurse is preparing to perform a fecal occult blood test of stool specimens for a client. Which of the following actions should the nurse plan to take?
- A. Ensure that the stool specimen does not contain urine.
- B. Wear sterile gloves when handling the stool specimen.
- C. Repeat the test three times using the same stool specimen.
- D. Have the client defecate into a bedpan that contains a small amount of water.
Correct Answer: A
Rationale: Urine contamination can cause false positives, compromising test accuracy.
A nurse is caring for a client who has insomnia. Which of the following actions should the nurse take?
- A. Use overhead lighting when checking equipment.
- B. Keep the door to the client's room closed.
- C. Provide the client with snug-fitting nightwear.
- D. Administer prescribed diuretics in the evening.
Correct Answer: B
Rationale: Closing the door reduces noise, promoting a sleep-conducive environment.
A nurse is performing a wound irrigation for a client who has methicillin-resistant Staphylococcus aureus. When removing personal protective equipment, which of the following pieces should the nurse remove first?
- A. Gloves
- B. Gown
- C. Goggles
- D. Mask
Correct Answer: A
Rationale: Removing gloves first prevents hand contamination when removing other PPE.
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