Nokea
Available is diphenhydramine 50 mg/mL. How many ml should the nurse administer? (Round to the nearest tenth)
Correct Answer: 0.6
Rationale: To determine the correct amount of diphenhydramine to administer, we can use the formula: Volume (mL) = Desired dose (mg) / Concentration (mg/mL). In this case, the desired dose is 50 mg and the concentration is 50 mg/mL. So, Volume = 50 mg / 50 mg/mL = 1 mL. Since we need to round to the nearest tenth, the correct answer is 0.6 mL. This is because 1 mL is equivalent to 50 mg, and since we only need to administer 50 mg, we use 0.6 mL. Other choices are incorrect as they do not adhere to the calculation based on the concentration and desired dose.
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Which of the following findings should the nurse identify as a manifestation of severe dehydration?
- A. Capillary refill time 3 seconds
- B. Sunken anterior fontanel
- C. Weight loss of 5%
- D. Produces tears when crying
Correct Answer: B
Rationale: The correct answer is B: Sunken anterior fontanel. This finding is indicative of severe dehydration in infants, as it suggests significant fluid loss and decreased tissue turgor. A sunken fontanel is a late sign of dehydration. Choice A is incorrect as a capillary refill time of 3 seconds is within normal limits. Choice C may be seen in mild to moderate dehydration, but severe dehydration would involve a greater weight loss. Choice D is not specific to dehydration, as tear production can still occur even in cases of dehydration.
A nurse in an emergency department is caring for a 3-month-old infant. Which of the following actions should the nurse take?
- A. Administer ceftriaxone.
- B. Administer pneumococcal conjugate vaccine.
- C. Initiate serum glucose testing every 1 hr.
- D. Initiate neutropenic precautions.
Correct Answer: A
Rationale: The correct answer is A: Administer ceftriaxone. In infants, ceftriaxone is commonly used for treating bacterial infections due to its broad-spectrum coverage. It is important to initiate prompt treatment in infants to prevent complications. Administering a pneumococcal conjugate vaccine (choice B) is important for prevention but not an immediate action in this scenario. Initiating serum glucose testing every 1 hr (choice C) is not necessary unless there are specific indications, as it may cause unnecessary stress to the infant. Neutropenic precautions (choice D) are not relevant in this case as there is no indication of neutropenia.
A nurse is reviewing the child's medical record. Which of the following medications should the nurse expect the provider to prescribe or reconcile from the child's home medication list?
- A. Water-soluble vitamins
- B. Acetaminophen
- C. Dornase alfa
- D. Meperidine
- E. Pancreatic lipase
Correct Answer: A,C,E
Rationale: The correct answers are A, C, and E. A nurse reviewing a child's medical record should expect the provider to prescribe or reconcile water-soluble vitamins (A) for essential nutrients, Dornase alfa (C) for cystic fibrosis to help clear mucus, and Pancreatic lipase (E) for pancreatic insufficiency to aid in digestion. Acetaminophen (B) is a common over-the-counter pain reliever but may not be specifically required based on the child's condition. Meperidine (D) is a narcotic analgesic with potential side effects and is not typically used in pediatric patients.
Which of the following actions should the nurse take first?
- A. Observe the child's throat with a flashlight.
- B. Give the child small sips of water.
- C. Administer an analgesic.
- D. Offer the child an ice collar.
Correct Answer: A
Rationale: The correct answer is A: Observe the child's throat with a flashlight. This is the first action the nurse should take as it helps assess for any signs of inflammation, infection, or obstruction in the throat, which could be causing the child's symptoms. By observing the throat, the nurse can gather important information to guide further interventions.
Choice B: Giving the child small sips of water can be important but should come after assessing the throat to ensure it is safe to swallow. Choice C: Administering an analgesic should be based on the assessment findings, not the first action. Choice D: Offering an ice collar is not indicated until the cause of the symptoms is identified.
Which of the following actions should the nurse take?
- A. Inform the client to contact the pharmacy regarding any questions related to the medication.
- B. Provide instructions to the client's parent with the client present.
- C. Instruct the client's parents to write down the information that is being provided.
- D. Ask how the client prefers to learn new information.
Correct Answer: D
Rationale: The correct answer is D: Ask how the client prefers to learn new information. This action is client-centered and promotes individualized care by understanding the client's preferred learning style. It helps tailor the teaching approach to best meet the client's needs, leading to improved understanding and compliance.
Choice A is incorrect because the nurse should provide medication information directly to the client instead of redirecting to the pharmacy.
Choice B is incorrect as it does not involve the client in the learning process, which is essential for effective education.
Choice C is incorrect as it focuses on the parents rather than the client, missing the opportunity to engage the client directly.
Overall, choice D stands out for its client-focused approach, making it the most appropriate action in this scenario.