A primary health care provider prescribes acetaminophen liqu...

A primary health care provider prescribes acetaminophen liquid 450 mg orally every 4 hours PRN for pain. The medication label reads 160 mg/5 mL. The nurse prepares how many milliliters (mL) to administer one dose? Fill in the blank and record your answer to the nearest whole number.

Correct Answer: 14 mL

Rationale: Use the formula for calculating medication dosages. Formula: Desired Ã— Volume / Available = mL per dose. 450 mg Ã— 5 mL / 160 mg = 14 mL.

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The nurse is caring for a client who had an orthopedic injury of the leg that required surgery and the application of a cast. Postoperatively, which nursing assessment is of highest priority to assure client safety?

A. Monitoring for heel breakdown
B. Monitoring for bladder distention
C. Monitoring for extremity shortening
D. Monitoring for blanching ability of toe nail beds

Correct Answer: D

Rationale: With cast application, concern for compartment syndrome development is of the highest priority. If postsurgical edema compromises circulation, the client will demonstrate numbness, tingling, loss of blanching of toenail beds, and pain that will not be relieved by opioids. Although heel breakdown, bladder distention, or extremity lengthening or shortening can occur, these complications are not potentially life-threatening complications.

The nurse is caring for a client who has been placed in skin traction. Which action by the nurse provides for countertraction to reduce shear and friction?

A. Using a footboard
B. Providing an overhead trapeze
C. Slightly elevating the foot of the bed
D. Slightly elevating the head of the bed

Correct Answer: C

Rationale: The part of the bed under an area in traction is usually elevated to aid in countertraction. For the client in skin traction (which is applied to a leg), the foot of the bed is elevated. Option 3 provides a force that opposes the traction force effectively without harming the client. A footboard, an overhead trapeze, or elevating the head of the bed is not used to provide countertraction.

The nurse provides information to a client diagnosed with insulin-dependent diabetes mellitus. Which manifestations resulting from a blood glucose level less than 70 mg/dL (4 mmol/L) should the nurse include in the information? Select all that apply.

A. Hunger
B. Sweating
C. Weakness
D. Nervousness
E. Cool clammy skin
F. Increased urinary output

Correct Answer: A,B,C,D,E

Rationale: Hypoglycemia is characterized by a blood glucose level less than 70 mg/dL (4 mmol/L). Clinical manifestations of hypoglycemia include hunger, sweating, weakness, nervousness, cool clammy skin, blurred vision or double vision, tachycardia, and palpitations. Increased urinary output is a manifestation of hyperglycemia.

A client has a total serum calcium level of 7.5 mg/dL (1.88 mmol/L). Which clinical manifestations should the nurse expect to note on assessment of the client? Select all that apply.

A. Constipation
B. Muscle twitches
C. Negative Chvostek's sign
D. Positive Trousseau's sign
E. Hyperactive deep tendon reflexes
F. Prolonged ST interval on electrocardiogram (ECG)

Correct Answer: B,D,E,F

Rationale: Hypocalcemia is a total serum calcium level less than 9 mg/dL (2.25 mmol/L). Clinical manifestations include muscle twitches, hyperactive deep tendon reflexes, positive Trousseau's sign, and prolonged ST interval on ECG. Negative Chvostek's sign and constipation are not associated with hypocalcemia.

The emergency department nurse is assessing a client who abruptly discontinued benzodiazepine therapy and is experiencing withdrawal. Which manifestations of withdrawal should the nurse expect to note? Select all that apply.

A. Tremors
B. Sweating
C. Lethargy
D. Agitation
E. Nervousness
F. Muscle weakness

Correct Answer: A,B,D,E

Rationale: Benzodiazepines should not be abruptly discontinued because withdrawal symptoms are likely to occur. Withdrawal symptoms include tremor, sweating, agitation, nervousness, insomnia, anorexia, and muscular cramps. Withdrawal symptoms from long-term, high-dose benzodiazepine therapy include paranoia, delirium, panic, hypertension, and status epilepticus. Lethargy is not associated with benzodiazepine withdrawal.