Nokea
A nurse is preparing to administer ziprasidone 10 mg IM every 6 hr. Available is ziprasidone 20 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 0.5
Rationale: The correct answer is 0.5 mL. To calculate this, first determine the total dose needed per administration (10 mg). Then, divide the total dose by the concentration of the medication (20 mg/mL) to find the volume to administer per dose (10 mg ÷ 20 mg/mL = 0.5 mL). This ensures the patient receives the correct amount of medication. Other choices are incorrect because they do not accurately calculate the volume needed for the specified dose. For example, choosing a higher volume would result in overdosing the patient, while choosing a lower volume would underdose the patient. The correct calculation is essential to ensure the patient's safety and therapeutic effectiveness.
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A nurse is instructing a client who has GERD about positions that can help minimize the effects of reflux during sleep. Which of the following statements indicates to the nurse that the client understands the instructions?
- A. I will lie on my left side to sleep at night.
- B. I will lie on my right side to sleep at night.
- C. I will sleep on my back with my head flat.
- D. I will sleep on my stomach with my head flat.
Correct Answer: A
Rationale: The correct answer is A: "I will lie on my left side to sleep at night." This position helps prevent acid from flowing back into the esophagus due to the anatomical positioning of the stomach and esophagus. When lying on the left side, the stomach is positioned below the esophagus, reducing the likelihood of reflux.
Incorrect choices:
B: Lying on the right side can worsen reflux symptoms as it allows stomach acid to flow back into the esophagus more easily.
C: Sleeping on the back with the head flat may not be as effective in preventing reflux compared to the left side position.
D: Sleeping on the stomach with the head flat can exacerbate reflux symptoms by putting pressure on the stomach and pushing acid back up into the esophagus.
Upon assessment, Cullen’s sign is noted. What complication of acute pancreatitis would the nurse suspect that the client might have?
- A. Pancreatic pseudocyst.
- B. Electrolyte imbalance.
- C. Internal bleeding.
- D. Pleural effusion.
Correct Answer: C
Rationale: Rationale: Cullen's sign is bluish discoloration around the umbilicus, indicating internal bleeding in acute pancreatitis. This occurs due to retroperitoneal hemorrhage tracking to the periumbilical area. Choices A, B, and D are not associated with Cullen's sign. Pancreatic pseudocyst may present with epigastric pain, electrolyte imbalance with nausea and vomiting, and pleural effusion with dyspnea.
A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation. Which of the following findings should the nurse plan to monitor for and report to the provider immediately?
- A. Irregular pulse.
- B. Persistent fatigue.
- C. Dependent edema.
- D. Slurred speech.
Correct Answer: D
Rationale: The correct answer is D: Slurred speech. Slurred speech can be a sign of a potential stroke, which can occur in patients with atrial fibrillation due to the risk of blood clots forming in the heart. This finding should be reported immediately to the provider for further evaluation and intervention to prevent further complications. Monitoring for slurred speech helps in early detection and prompt management of a potential stroke.
Other choices such as A: Irregular pulse, B: Persistent fatigue, and C: Dependent edema are common in patients with heart failure and atrial fibrillation but are not immediate concerns requiring urgent intervention like slurred speech indicating a potential stroke.
A nurse is assessing a client who is 48 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?
- A. Respiratory rate 18/min.
- B. Blood pressure 102/66 mm Hg.
- C. Yellow-green drainage on the surgical incision.
- D. Straw-colored urine from an indwelling urinary catheter.
Correct Answer: C
Rationale: The correct answer is C because yellow-green drainage on the surgical incision can indicate an infection, which is a critical postoperative complication that requires immediate attention from the provider. This finding suggests the presence of pus or other infectious material in the wound, increasing the risk of further complications like wound dehiscence or systemic infection. Reporting this to the provider promptly allows for timely intervention such as wound exploration, debridement, and initiation of appropriate antibiotics.
The other choices are not as concerning in the immediate postoperative period:
A: Respiratory rate within normal range
B: Blood pressure within normal range
D: Straw-colored urine is expected from an indwelling urinary catheter, indicating adequate kidney function and hydration.
A nurse is providing teaching to a client about preventing skin cancer. Which of the following client statements indicates a need for further teaching?
- A. Eating a high fiber diet will reduce my risk for developing skin cancer.
- B. I should check my skin monthly for any changes.
- C. I should avoid the use of tanning booths.
- D. I should use sunscreen even on cloudy days.
- E. I should use sunscreen even on cloudy days.
Correct Answer: A
Rationale: The correct answer is A. Eating a high fiber diet does not directly reduce the risk of developing skin cancer. The other choices are more directly related to preventing skin cancer, such as checking skin for changes (B), avoiding tanning booths (C), and using sunscreen on both sunny and cloudy days (D and E). Therefore, further teaching is needed to clarify the misconception about the role of a high fiber diet in preventing skin cancer.