A nurse is providing discharge teaching to the parent of a child who is prescribed diphenhydramine 25 mg elixir every 4 hours as needed. The amount available is diphenhydramine elixir 12.5 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: 2
Rationale: Correct Answer: 2 mL
Rationale: To calculate the mL per dose, divide the prescribed mg by the concentration in mg/mL. 25 mg ÷ 12.5 mg/mL = 2 mL. This dosage ensures the correct amount of diphenhydramine is administered.
Summary of Other Choices:
A: Incorrect, as it does not calculate the dosage correctly.
B-G: Irrelevant as they do not provide any calculations or rationale for the correct dosage.
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A nurse is caring for a client who is postoperative following a transurethral resection of the prostate. Which of the following complications is the priority for the nurse to monitor for?
- A. Hemorrhage
- B. Infection
- C. Urinary retention
- D. Pain
Correct Answer: A
Rationale: The correct answer is A: Hemorrhage. Postoperative hemorrhage is a critical complication following a transurethral resection of the prostate due to the rich blood supply in the area. It can lead to hypovolemic shock and requires immediate intervention to prevent further complications. Monitoring for signs of bleeding such as increased heart rate, decreased blood pressure, and decreased urine output is crucial.
B: Infection is an important complication to monitor for but is not as immediately life-threatening as hemorrhage.
C: Urinary retention can occur postoperatively but is not as urgent as hemorrhage.
D: Pain management is important for the client's comfort, but it is not the priority in this situation.
In summary, monitoring for hemorrhage is crucial as it is the most life-threatening complication that requires immediate attention compared to the other options.
A nurse is caring for a client who is receiving heat applications using an aquathermia pad. Which of the following actions should the nurse take when applying the pad?
- A. Leave the pad in place for at least 40 minutes
- B. Set the pad’s temperature to 42.2°C (108°F)
- C. Use safety pins to keep the pad in place
- D. Stop the treatment if the client’s skin becomes red
Correct Answer: D
Rationale: The correct answer is D: Stop the treatment if the client’s skin becomes red. This is important because redness indicates potential skin damage or burns due to excessive heat exposure. It is crucial to monitor the client's skin during heat application to prevent harm. Choice A is incorrect because leaving the pad in place for a specific duration can lead to skin damage if the temperature is too high. Choice B is incorrect as setting the pad's temperature too high can cause burns. Choice C is incorrect as safety pins can cause injury or discomfort to the client. Therefore, the correct action is to closely monitor the client's skin for any signs of redness and stop the treatment immediately if redness occurs to prevent further harm.
A nurse is caring for a client who has delusional behavior and states, 'I can’t go to group therapy today. I am expecting a high-level official to visit me.' The nurse responds, 'I understand, but it is time for group therapy and we expect everyone to attend. Let’s walk over together.' For which of the following reasons is the nurse’s response considered therapeutic?
- A. It clearly articulates the expectations of the client.
- B. It demonstrates empathy towards the client.
- C. It sets limits on the client’s manipulative behavior.
- D. It uses reflection when talking with the client.
Correct Answer: B
Rationale: The correct answer is B: It demonstrates empathy towards the client. By acknowledging the client's feelings and showing understanding, the nurse is building a therapeutic relationship based on empathy. This approach helps the client feel heard and validated, fostering trust and cooperation. The other choices are incorrect because: A) while the response does articulate expectations, it does not address the client's emotions or perspective; C) while setting limits is important, the response does not directly address manipulative behavior; D) reflection involves paraphrasing or summarizing the client's thoughts, which is not evident in the nurse's response.
A nurse is preparing a response protocol for botulism as a bioterrorism agent. The nurse should prepare the protocol based on which of the following information? (Select all that apply.)
- A. Botulism is acquired through direct contact with an infected person.
- B. Notify the Centers for Disease Control and Prevention (CDC) when more than three cases are confirmed.
- C. Botulism can produce paralysis within 12 to 72 hours following exposure.
- D. Vomiting and diarrhea are expected findings following exposure.
- E. Botulism is a toxin found in castor beans.
Correct Answer: C,D
Rationale: The correct answers are C and D. Choice C is correct because botulism can indeed produce paralysis within 12 to 72 hours following exposure. This is crucial information for early detection and treatment. Choice D is also correct because vomiting and diarrhea are not typical symptoms of botulism. The toxin primarily affects the nervous system, leading to symptoms such as muscle weakness and paralysis. Choices A, B, and E are incorrect. Botulism is not acquired through direct contact with an infected person (A), the CDC should be notified immediately upon suspicion of botulism, not after a certain number of cases (B), and botulism toxin is not found in castor beans (E).
A nurse is caring for a client who is receiving a continuous IV infusion of heparin. Which of the following actions should the nurse take?
- A. Administer 50,000 units of heparin by IV bolus every 12 hours.
- B. Have vitamin K available on the nursing unit.
- C. Use tubing specific for heparin sodium when administering the infusion.
- D. Check the activated partial thromboplastin time (aPTT) every 6 hours.
Correct Answer: D
Rationale: The correct answer is D: Check the activated partial thromboplastin time (aPTT) every 6 hours. This is crucial to monitor the therapeutic effect of heparin, ensuring the client's blood does not become too thin or too thick. Regular aPTT monitoring helps adjust the heparin infusion rate to maintain the desired anticoagulant effect.
Explanation of why other choices are incorrect:
A: Administering a large dose of heparin by IV bolus is dangerous and can lead to bleeding complications. Incorrect.
B: Having vitamin K available is not specifically related to managing heparin therapy. Incorrect.
C: Using tubing specific for heparin is important but is not the priority action in this scenario. Incorrect.
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