Nokea
The healthcare provider prescribes cefazolin 800 mg IM every six hours. The available vial is labeled, 'Cefazolin 1 gram,' and the instructions for reconstitution state, For IM use add 2.5 mL sterile water for Injection to provide a total volume of 3.0 mL. After reconstitution, the solution contains how many mg/mL? Enter numeric value only. If rounding is required, round to the nearest whole number.)
Correct Answer: 333
Rationale: One gram (1000 mg) reconstituted in 3.0 mL yields a concentration of 1000 mg / 3 mL = 333.33 mg/mL, rounded to 333 mg/mL.
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A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which observation warrants immediate intervention by the nurse?
- A. The client's chest x-ray Indicates decreased pleural effusion.
- B. The client's arterial blood gas result is a pH 7.35, PaCO, 35 mm Hg, HCO,-26 mEq (26 mmol/L), PaO, 85 mm Hg.
- C. The client has asymmetrical chest wall expansion.
- D. The client reports pain at the insertion site.
Correct Answer: C
Rationale: Asymmetrical chest wall expansion may indicate pneumothorax, a serious complication requiring immediate intervention.
History and Physical
Nurses' Notes
Orders
Imaging Studies
The client is a young male who appears to be 25 to 30 years old. He was found unconscious on a sidewalk by a jogger who was passing by. The jogger called an ambulance, and the emergency medical technicians (EMTS) transported the client to the hospital. The client is arousable but unable to say what his name is or what happened to him. A STAT head computed tomography (CT) scan in the emergency department showed no abnormalities, so the client will be admitted to the medical floor for observation and further tests.
The healthcare provider comes to the bedside following the seizure and prescribes phenytoin. The nurse administers the phenytoin as prescribed. Which possible side effect(s) of phenytoin should the nurse assess for after administration? Select all that apply.
- A. Vomiting
- B. Altered blood coagulation
- C. Visual disturbances
- D. Drowsiness
- E. Aphasia
- F. Ataxia
Correct Answer: B,C,D,F
Rationale: Phenytoin may cause altered coagulation, visual disturbances, drowsiness, and ataxia, affecting safety and monitoring needs.
The client's laboratory results indicate that the serum potassium level is 2.5 mEq/L (2.5 mmol/L). Which action should the nurse take?
- A. Prepare to administer a glucose, then insulin, then potassium infusion.
- B. Inform the healthcare provider of the need for potassium replacement.
- C. Instruct the client to Increase dally Intake of potassium rich foods.
- D. Change the plan of care to Include hourly urinary output measurements.
Correct Answer: B
Rationale: Severe hypokalemia requires immediate potassium replacement, necessitating healthcare provider notification, rather than dietary changes or monitoring alone.
A client with heart failure (HF) returns to the clinic two weeks after adjustments were made to the prescribed cardiac glycoside, diuretic, and potassium supplement. The client's lungs are clear, heart rate is 58 beats/minute, and serum potassium level is 2.9 mEq/L (2.9 mmol/L). Which action is most important for the nurse to implement?
- A. Compare the weight with what it was at last visit.
- B. Report serum potassium to healthcare provider.
- C. Review the dietary history from the past week.
- D. Check the pretibial areas and ankles for edema.
Correct Answer: B
Rationale: Reporting hypokalemia (2.9 mEq/L) is critical to prevent arrhythmias, especially with cardiac glycosides.
A client is scheduled for a scleral buckling procedure after previously having multiple laser coagulation procedures done for retinal tears. Which Information about the immediate postoperative period should the nurse provide this client?
- A. Report reoccurring visual signs of retinal detachment.
- B. Maintain the head in one postoperative position.
- C. Watch for signs of infection in the surgical eye.
- D. Ambulate to the bathroom with assistance.
Correct Answer: A
Rationale: Reporting signs of retinal detachment is critical to ensure the success of the scleral buckling procedure.