Nokea
How many drops per minute should be delivered?
- A. 6
- B. 17
- C. 50
- D. 100
Correct Answer: B
Rationale: The standard drip factor for an IV infusion set is typically 15 drops per milliliter. To calculate drops per minute, you would multiply the flow rate in milliliters per hour by the drip factor and divide by 60 minutes per hour.
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A nurse prepares to administer the medication in which muscle site?
- A. Deltoid
- B. Triceps
- C. Vastus lateralis
- D. Biceps
Correct Answer: C
Rationale: The nurse prepares to administer the medication in the vastus lateralis muscle site. This site is located on the thigh and is commonly used for intramuscular injections in infants, toddlers, and smaller children. It is preferred for its large and easily accessible muscle mass, making it suitable for injections. This muscle site is also less painful and has fewer major blood vessels and nerves, reducing the risk of complications during injection.
An adolescent asks the nurse what causes primary dysmenorrhea. The nurse's response should be based on which statement?
- A. It is an inherited problem.
- B. Excessive estrogen production causes uterine pain.
- C. There is no physiologic cause; it is a psychological reaction.
- D. There is a relation between prostaglandins and uterine contractility.
Correct Answer: D
Rationale: Primary dysmenorrhea is painful menstruation that occurs without any underlying gynecological conditions, such as endometriosis. The cause of primary dysmenorrhea is related to the release of prostaglandins during menstruation. Prostaglandins are lipid compounds that act as chemical messengers in the body, causing the uterus to contract and shed its lining during menstruation. High levels of prostaglandins can lead to increased uterine muscle contractions, resulting in pain. Therefore, the nurse should explain to the adolescent that there is a relation between prostaglandins and uterine contractility as the cause of primary dysmenorrhea.
A client with colon cancer requires a permanent colostomy because of the tumor location. After surgery, the client must learn how to irrigate the colostomy. When irrigating, how far into the stoma should the client insert the lubricated catheter?
- A. 0.25" to 0.5"
- B. 2" to 4"
- C. 1" to 1.5"
- D. 5" to 7"
Correct Answer: C
Rationale: When irrigating a colostomy, the client should insert the lubricated catheter approximately 1 to 1.5 inches (2.5 to 4 cm) into the stoma. This depth ensures that the catheter reaches the optimal level within the colon to effectively irrigate and cleanse the colon contents. Inserting the catheter too shallow may not reach the colon, while inserting it too deep can cause discomfort or injury to the lining of the colon. It is important for the client to be educated on the correct technique and depth for colostomy irrigation to maintain bowel regularity and health.
The nurse understands that labyrinthitis is treated primarily with which of the ff. drug categories?
- A. Antihistamines
- B. Anti-inflammatories
- C. Antispasmotics
- D. Antiemetics
Correct Answer: A
Rationale: Labyrinthitis is an inner ear disorder that is often caused by a viral infection. Antihistamines are commonly used in the treatment of labyrinthitis to help reduce symptoms such as dizziness, nausea, and vomiting. Antihistamines work by blocking the effects of histamine, which is a chemical in the body that can cause these symptoms. Additionally, antihistamines can help alleviate any associated allergies or inflammation in the inner ear that may be contributing to the condition. Other treatment options for labyrinthitis may include vestibular rehabilitation exercises, antiemetics for nausea and vomiting, and medications to manage dizziness.
A client is admitted to the ICU, which laboratory result must be reported immediately to the physician?
- A. Hematocrit 48%
- B. paCO2 38 mm Hg
- C. platelets 18,000
- D. WBC count 8000
Correct Answer: C
Rationale: A platelet count of 18,000 is significantly low, indicating a condition known as thrombocytopenia, which can lead to a risk of bleeding. In a critical care setting like the ICU, low platelet counts need to be addressed urgently to prevent serious complications such as hemorrhage. This result must be reported immediately to the physician so that appropriate interventions, such as transfusion of platelets, can be initiated promptly to manage the patient's condition effectively. Hematocrit, paCO2, and WBC count may also be important parameters to monitor in an ICU patient, but the critically low platelet count poses the most immediate threat to the patient's well-being and requires urgent attention.