Nokea
A nurse is preparing to administer lorazepam 2 mg PO. Available in lorazepam 1 mg tablets. How many tablets should the nurse administer?
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: B
Rationale: The correct answer is B: 2 tablets. The nurse needs to administer 2 mg of lorazepam, and each tablet is 1 mg. Therefore, to achieve the total dose of 2 mg, the nurse should administer 2 tablets. Administering 1 tablet (choice A) would only provide 1 mg, which is insufficient. Choices C and D would exceed the required dose of 2 mg, leading to potential overdose and adverse effects.
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A nurse is caring for a client who has a thrombus and is receiving a continuous infusion of heparin. The client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses should the nurse make?
- A. The time it takes for heparin to dissolve a clot depends on the size of the clot.
- B. The time it takes for heparin to dissolve a clot varies between clients.
- C. Usually, it takes at least 2 to 3 days for heparin to dissolve a clot.
- D. Heparin prevents new clots from forming rather than dissolving existing ones.
Correct Answer: D
Rationale: Correct Answer: D. Heparin prevents new clots from forming rather than dissolving existing ones.
Rationale: Heparin works by inhibiting the formation of new clots rather than actively dissolving existing clots. It does not directly break down clots but rather prevents them from getting larger or new clots from forming. Therefore, it is important for the nurse to educate the client that heparin's primary function is to prevent further clot formation and not to dissolve the existing clot.
Summary of other choices:
A: The time it takes for heparin to work is not dependent on the size of the clot.
B: While response times may vary between clients, the primary action of heparin remains the same.
C: Providing a specific time frame for clot dissolution is inaccurate as heparin does not dissolve clots.
E, F, G: Options not provided.
A nurse is caring for a client who has hypertension and is to start taking Atenolol. The nurse should instruct the client to monitor which of the following findings is an adverse effect of this medication.
- A. Constipation.
- B. Postural hypotension.
- C. Dermatitis.
- D. Cardiac arrest.
Correct Answer: B
Rationale: The correct answer is B: Postural hypotension. Atenolol is a beta-blocker that can cause a drop in blood pressure when changing positions, leading to postural hypotension. This is an adverse effect that clients need to be aware of. Constipation (A) is not a common side effect of Atenolol. Dermatitis (C) is also not typically associated with this medication. Cardiac arrest (D) is a severe complication but not a common adverse effect of Atenolol. Postural hypotension is the most likely adverse effect, making it the correct answer.
A nurse is reinforcing teaching for a client who has angina pectoris and a new prescription to apply a nitroglycerin transdermal patch daily. Which of the following instructions should the nurse give the client?
- A. Use an old patch with medication residue on the inside and discard it in a closed receptacle.
- B. Keep a nitroglycerin patch in place for 72 hours before replacing.
- C. Apply the patch to a hairy area of the skin for better adherence.
- D. Cleanse the skin before applying a nitroglycerin patch.
Correct Answer: D
Rationale: The correct answer is D - Cleanse the skin before applying a nitroglycerin patch. This instruction is crucial to ensure proper absorption of the medication and prevent skin irritation. Cleansing the skin removes dirt, oils, and sweat, allowing the patch to adhere properly and deliver the medication effectively. Using an old patch (A) can lead to inconsistent dosing and decreased effectiveness. Keeping the patch in place for 72 hours (B) can cause skin irritation and decrease medication potency. Applying the patch to a hairy area (C) may reduce adherence and interfere with proper contact with the skin. Therefore, instructing the client to cleanse the skin before application is the most appropriate choice.
A nurse in the emergency department is assisting with the care of a client who has a deep laceration on her left lower forearm and is bleeding heavily from the wound. Which of the following actions should the nurse take first?
- A. Apply a tourniquet just above the wound.
- B. Place the client in a modified Trendelenburg position.
- C. Apply pressure directly to the wound.
- D. Settle the client in a reclining position.
Correct Answer: C
Rationale: The correct action is to apply pressure directly to the wound first. This is crucial to control the bleeding and prevent further blood loss. Applying pressure helps to promote clotting and reduce the risk of hypovolemic shock. It is the immediate and most effective intervention to manage the situation.
Choice A (Apply a tourniquet just above the wound) is incorrect because tourniquets should be used as a last resort due to the risk of tissue damage and potential complications.
Choice B (Place the client in a modified Trendelenburg position) is incorrect as this position is not recommended for patients with bleeding as it can increase intracranial pressure and worsen the situation.
Choice D (Settle the client in a reclining position) is incorrect because the priority is to control the bleeding first before adjusting the client's position.
A nurse is preparing to administer dextrose 5% in water IV to infuse at 100 mL/60 min. The drop factor on the manual IV tubing is 60 gtt/mL. The nurse should set the IV flow rate to deliver how many gtt/min. (Round to the nearest whole number.).
- A. 100 gtt/min.
Correct Answer: A
Rationale: The correct answer is A: 100 gtt/min. To calculate the IV flow rate, we first convert the prescribed volume (100 mL) and time (60 min) to drop factor per minute. 100 mL / 60 min = 1.67 mL/min. Then, we convert mL to drops using the drop factor (60 gtt/mL): 1.67 mL/min * 60 gtt/mL = 100.2 gtt/min. Rounding to the nearest whole number, the nurse should set the IV flow rate to 100 gtt/min.
Other choices (B-G) are incorrect as they are not calculated based on the given information and would lead to incorrect infusion rates.