Nokea
A nurse is preparing to administer morphine sulfate 2 mg IV bolus. Available is morphine sulfate 10 mg/mL. How many mL should the nurse administer per dose?
- A. 0.2 mL
- B. 0.4 mL
- C. 0.6 mL
- D. 0.8 mL
Correct Answer: A
Rationale: The nurse should administer 0.2 mL of morphine sulfate. To calculate this, divide the desired dose (2 mg) by the concentration of the available solution (10 mg/mL). 2 mg / 10 mg/mL = 0.2 mL. Therefore, the nurse should administer 0.2 mL of morphine sulfate. Choices B, C, and D are incorrect as they do not reflect the accurate calculation based on the provided concentration and desired dose.
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A nurse has provided education to a client regarding prescribed levothyroxine sodium. Which of the following client statements demonstrates understanding of medication administration?
- A. I should take my medication as needed to alleviate symptoms
- B. I should take the medication in divided doses to ensure therapeutic drug levels
- C. I should take the medication in the morning to prevent insomnia
- D. I should take the medication on a full stomach
Correct Answer: C
Rationale: Levothyroxine should be taken once in the morning to prevent insomnia and maintain therapeutic levels.
A nurse is caring for a client receiving IV vancomycin. The nurse notes flushing of the client's neck and chest. Which of the following actions should the nurse take?
- A. Stop the infusion
- B. Document the findings as a harmless reaction
- C. Slow the infusion rate
- D. Administer diphenhydramine
Correct Answer: C
Rationale: The correct action for the nurse to take when a client receiving IV vancomycin shows flushing of the neck and chest is to slow the infusion rate. Flushing is a common sign of Red Man Syndrome, which is associated with rapid infusions of vancomycin. Slowing down the infusion rate can help prevent further flushing and the development of Red Man Syndrome. Stopping the infusion (Choice A) may be too drastic if the symptoms are mild and can be managed by slowing the rate. Documenting the findings as a harmless reaction (Choice B) is incorrect because flushing should be addressed promptly to prevent complications. Administering diphenhydramine (Choice D) is not the initial or best intervention for flushing associated with vancomycin; slowing the infusion rate is the priority.
A nurse is reviewing the medical record of a client who is prescribed acetaminophen for pain. Which of the following lab values should the nurse monitor to identify an adverse effect of the medication?
- A. Serum glucose
- B. Serum creatinine
- C. Serum potassium
- D. Serum bilirubin
Correct Answer: B
Rationale: The correct answer is B: Serum creatinine. Acetaminophen is metabolized by the liver, so serum creatinine levels should be monitored for potential hepatotoxicity. Monitoring serum creatinine can help detect liver damage, a potential adverse effect of acetaminophen. Choices A, C, and D are incorrect because serum glucose is not directly affected by acetaminophen, serum potassium is not typically monitored for acetaminophen adverse effects, and serum bilirubin is more related to bile metabolism rather than acetaminophen-induced hepatotoxicity.
A nurse is caring for a client receiving patient-controlled analgesia (PCA). Which of the following interventions should the nurse take while caring for this client?
- A. Advise the client to use the pump sparingly to prevent addiction
- B. Encourage the client to use the PCA before dressing changes
- C. Encourage the client's family to administer PCA while the client is sleeping
- D. Increase the client's 4-hour limit as needed
Correct Answer: B
Rationale: The correct answer is B because encouraging the client to use the PCA before dressing changes helps in managing pain proactively. Choice A is incorrect as PCA is a safe method of pain control when used appropriately, and the nurse should not suggest using it sparingly. Choice C is incorrect as only the client should operate the PCA to ensure they are in control of their pain management. Choice D is incorrect as changing the PCA limit without proper assessment and orders from the healthcare provider can lead to adverse effects.
A nurse is caring for a client prescribed digoxin. Which of the following should alert the nurse to possible digitalis toxicity?
- A. Anorexia and weakness
- B. Hyperactivity and hunger
- C. Tachycardia and increased urination
- D. Polyphagia and polydipsia
Correct Answer: A
Rationale: The correct answer is A: Anorexia and weakness. These symptoms are early indicators of potential digitalis toxicity. Anorexia refers to a loss of appetite, which can be a sign of toxicity, and weakness can indicate an issue with digoxin. Choices B, C, and D are incorrect. Hyperactivity and hunger, tachycardia and increased urination, as well as polyphagia and polydipsia are not typically associated with digitalis toxicity.