Nokea
A nurse is preparing to administer ondansetron 4 mg IM stat. The amount available is ondansetron for injection 2 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. (Use a leading zero if it applies. Do not use a trailing zero))
Correct Answer: 2 mL
Rationale: 4 mg ÷ 2 mg/mL = 2 mL. The nurse should administer 2 mL.
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A nurse is reviewing the urinalysis results of a client who reports urinary frequency and burning. Which of the following findings should the nurse report to the provider?
- A. Urine specific gravity 1.020.
- B. Microscopic hematuria.
- C. Amber yellow urine color.
- D. Absence of glucose in the urine.
Correct Answer: B
Rationale: Microscopic hematuria indicates red blood cells in the urine, suggesting possible urinary tract infection or other pathology requiring further evaluation.
A nurse is administering morning medications and realizes that nifedipine was administered to the wrong client. Which of the following is the priority nursing action?
- A. Notify the charge nurse.
- B. Check the client's vital signs.
- C. Fill out an occurrence report according to institutional policy.
- D. Document an objective description of what has happened in the client's chart.
Correct Answer: B
Rationale: Checking the client's vital signs is the priority to assess for adverse effects, such as hypotension, ensuring immediate safety.
A nurse is contributing to the plan of care for an older adult client who has a WBC of 2000/mm³ after three rounds of chemotherapy. Which of the following interventions should the nurse include in the plan?
- A. Serve cooked fruit with meals.
- B. Report temperatures greater than 39.5°C (102.3°F) lasting more than 4 hours.
- C. Place the client in a room with negative-pressure airflow.
- D. Instruct client to use an incentive spirometer every 4 hours.
Correct Answer: A
Rationale: Serving cooked fruit reduces infection risk by eliminating pathogens, appropriate for a client with low WBC counts.
A nurse is reinforcing teaching with a client who has neutropenia. Which of the following instructions should the nurse include in the teaching?
- A. Take temperature weekly.
- B. Participate in gardening for mild exercise.
- C. Eat plenty of fresh fruits and vegetables.
- D. Avoid crowded places.
Correct Answer: D
Rationale: Avoiding crowded places reduces infection risk in neutropenic clients with low white blood cell counts.
A nurse is contributing to the plan of care for a client who is postoperative following a total hip arthroplasty. Which of the following information should the nurse include?
- A. Position the lower extremities so that they are touching.
- B. Ensure that the client's heels are touching the bed.
- C. Instruct the client to avoid movement of the affected leg.
- D. Prevent hip flexion of the affected extremity.
Correct Answer: D
Rationale: Preventing hip flexion of the affected extremity is correct because excessive hip flexion can increase the risk of dislocation after a total hip arthroplasty.