Nokea
A nurse is preparing to administer epoetin 50 units/kg via subcutaneous injection to a client who weighs 165 lb and has chronic kidney disease. How many units should the nurse administer?
- A. 3750 units
Correct Answer: A
Rationale: 165 lb = 75 kg; 50 units/kg × 75 kg = 3750 units, correct for stimulating RBC production in CKD.
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A nurse is assisting in the care of the client who is postoperative following a fasciotomy. Which of the following actions should the nurse take?
- A. Prepare to administer an antibiotic.
- B. Administer an analgesic.
- C. Restrict fluid intake.
- D. Prepare to obtain a wound culture.
- E. Initiate supplemental oxygen.
Correct Answer: B
Rationale: Post-fasciotomy, pain from surgical incision and prior compartment pressure is expected, making analgesia a priority to enhance comfort and mobility, aiding recovery. Antibiotics are proactive for infection, but no fever or purulent drainage (Exhibit) justifies immediate use prophylaxis may apply, not routine post-op. Fluid restriction contradicts hydration needs for healing and circulation, especially with serosanguinous drainage. Wound cultures are indicated for infection signs (e.g., redness, pus), not routine here with a dry, intact dressing. Pain management aligns with postoperative care principles unrelieved pain increases stress, delays ambulation, and risks chronicity making analgesic administration the most immediate, evidence-based action to support the client's well-being and surgical outcome.
A nurse is reinforcing teaching about the care of a client who has tinea corporis with a newly licensed nurse. Which of the following should the nurse include in the teaching?
- A. Place on airborne precautions.
- B. Avoid direct contact.
- C. Isolate for 24 hr. after lesions appear.
- D. Administer a broad-spectrum antibiotic.
Correct Answer: B
Rationale: Avoiding direct contact prevents the spread of tinea corporis, a fungal infection. Airborne precautions and antibiotics are inappropriate, and isolation isn't required beyond contact precautions.
A nurse enters a client's room and sees smoke coming from the trash can next to the client's bed. Which of the following actions should the nurse take first?
- A. Pull the fire alarm panel.
- B. Obtain a fire extinguisher.
- C. Remove the client from the room.
- D. Close the door to the client's room.
Correct Answer: C
Rationale: In a fire emergency, the RACE protocol (Rescue, Alarm, Contain, Extinguish) guides nursing actions, prioritizing safety. Option C is correct removing the client from the room first ensures their immediate safety from smoke inhalation or burns, the primary risk in this scenario. Option A, pulling the alarm, is crucial but secondary; the client's life takes precedence over alerting others. Option B, obtaining an extinguisher, delays rescue and assumes the nurse can safely fight the fire, which may not be feasible with smoke present. Option D, closing the door, helps contain the fire but traps the client in danger if done first. Rescuing the client aligns with the ethical duty to protect life, addresses the imminent threat of smoke (a leading cause of fire-related death), and allows subsequent steps (alarm, containment) to follow safely. This sequence reflects standard fire safety training and hospital policy, making it the nurse's first action.
A nurse is preparing to perform a blood glucose test. After performing hand hygiene and donning gloves, in which order should the nurse perform the following actions to obtain a capillary blood sample?
- A. Cleanse the site with an antiseptic swab.
- B. Allow the site to dry.
- C. Pierce the puncture site quickly.
- D. Squeeze the site gently to obtain a blood droplet.
- E. Apply blood to the test strip.
Correct Answer: A,B,C,D,E
Rationale: Steps are: Cleanse (A), dry (B), pierce (C), squeeze (D), and apply (E), ensuring a clean and accurate glucose reading.
A nurse is assisting with the care of a client who has a seizure disorder. Which of the following supplies should the nurse have at the client's bedside at all times?
- A. Suction equipment
- B. Padded tongue blades
- C. Backboard
- D. Wrist restraints
Correct Answer: A
Rationale: Suction equipment clears airways during a seizure, preventing aspiration. Tongue blades are outdated, and restraints or backboards are not standard bedside items for seizure care.