Nokea
The 6-month-old hospitalized with dehydration is being rehydrated with IV fluids. Which findings should indicate to the nurse that the treatment is having the desired effect? Select all that apply.
- A. Flat fontanelle
- B. Absence of crying
- C. Light yellow urine
- D. Rapid respirations
- E. Moist mucous membranes
Correct Answer: A,C,E
Rationale: A: Flat (rather than depressed) fontanelles indicate good hydration, which is the desired effect of IV rehydration. B: Absence of crying is not related to improved hydration status. C: Light-colored urine indicates good hydration, which is the desired effect of IV rehydration. D: Rapid respirations may indicate dehydration. E: Moist mucous membranes indicate good hydration, which is the desired effect of IV rehydration.
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The nurse is preparing to administer morphine sulfate IV to the child in severe pain. The child has an IV infusion of D5W at 50 mL/hr through a PICC. Which intervention is best when administering the medication?
- A. Disconnect the infusion, inject 3 mL of normal saline, and give the morphine sulfate undiluted.
- B. Question the prescribed medication because morphine sulfate cannot be given through a PICC line.
- C. Give the morphine sulfate undiluted into the existing IV tubing's medication port closest to the child.
- D. Dilute the morphine sulfate with 5 mL of NS and give over 5 minutes into the IV tubing port closest to the child.
Correct Answer: D
Rationale: A: Unnecessary IV disconnections increase the risk for infection. Morphine sulfate is compatible with D5W. B: Morphine sulfate can be administered into a PICC access device. C: Administering undiluted morphine sulfate to a child increases the risk of adverse effects. D: The nurse should dilute the morphine sulfate before administration to prevent too-rapid administration and adverse effects. A single dose should be given over 4 to 5 minutes.
The nurse is caring for the child from Italy. The child is crying, and the interpreter is stating that the child has extreme pain. What should be the nurse's priority?
- A. Administer morphine sulfate 1 mg intravenously as prescribed.
- B. Have the child's mother, who knows limited English, ask the child what hurts.
- C. Assess the level of the child's pain using an appropriate FACES pain rating scale.
- D. Ask the HCP to change the pain medication dosage due to inadequate pain control.
Correct Answer: C
Rationale: A: The nurse's judgment regarding the choice of pain medication and dose should be based on the reported level of pain. B: The nurse should do an independent assessment because sometimes information can be misinterpreted if there is limited knowledge of the language. C: Assessment should be completed prior to a pain intervention. The FACES pain-rating scale has been translated into a variety of languages. D: There is no information indicating the need for the pain medication dose to be changed.
The nurse is reviewing client information for adverse effects of trazodone. Which finding should the nurse identify as an adverse effect unique to trazodone?
- A. Priapism
- B. Weight gain
- C. Hepatic failure
- D. Cardiac dysrhythmias
Correct Answer: A
Rationale: Prolonged or inappropriate erections (priapism) are a rare but problematic side effect of treatment with trazodone (Oleptro).
An infection in a central venous access device is not eliminated by giving antibiotics through the catheter. How might bacterial glycocalyx contribute to this?
- A. It protects the bacteria from antibiotic and immunologic destruction.
- B. Glycocalyx neutralizes the antibiotic, rendering it ineffective.
- C. It competes with the antibiotic for binding sites on the microbe.
- D. Glycocalyx provides nutrients for microbial growth.
Correct Answer: A
Rationale: Glycocalyx is a viscous polysaccharide or polypeptide slime that covers microbes, enhancing adherence to surfaces, resisting phagocytic engulfment, and preventing antibiotics from contacting the microbe.
The client with advanced prostate cancer is receiving abarelix. Due to the effects of the medication, what should be the nurse's priority?
- A. Review with the client strategies to reduce constipation.
- B. Monitor the client for breast tenderness and nipple pain.
- C. Observe the client for 30 minutes after giving abarelix.
- D. Teach the client methods to fall asleep and stay asleep.
Correct Answer: C
Rationale: A: Constipation is a side effect of abarelix and is important to monitor but is not the priority. B: Breast pain with tenderness is a side effect of abarelix and is important to monitor but is not the priority. C: The nurse's priority should be to observe the client for at least 30 minutes after abarelix (Plenaxis) administration. The risk of a severe allergic reaction increases with each dose and can occur within a short time after administration. D: Sleep disturbances are common side effects of abarelix, and teaching about sleep hygiene is important but not the priority.