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The healthcare provider prescribes Cytovene 375 mg every 12 hours to infuse over 90 minutes. The pharmacy delivers Cytovene 375 mg in a 150 mL IV bag. How many ml/hour should the nurse program the infusion pump?
- A. 50 ml/hour.
- B. 75 ml/hour.
- C. 100 ml/hour.
- D. 125 ml/hour.
Correct Answer: C
Rationale: To infuse 150 mL over 90 minutes, the pump should be set to 100 ml/hour (150 mL / 1.5 hours). This rate ensures that the medication is delivered at the proper rate as prescribed. Choices A, B, and D are incorrect because they do not reflect the correct calculation based on the volume of the IV bag and the infusion duration provided in the question.
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While assisting a female client to the toilet, the client begins to have a seizure, and the nurse eases her to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first?
- A. Document details of the seizure activity.
- B. Observe for lacerations on the tongue.
- C. Observe for prolonged periods of apnea.
- D. Evaluate for evidence of incontinence.
Correct Answer: A
Rationale: Documenting details of the seizure activity is the priority intervention as it is crucial for medical records and future care planning. This documentation can provide vital information for healthcare providers in understanding the type, duration, and characteristics of the seizure. Observing for lacerations on the tongue, prolonged periods of apnea, or evidence of incontinence are important assessments, but they come after documenting the seizure activity.
Before selecting which medication to administer, which action should the nurse implement if a postoperative client reports incisional pain and has two prescriptions for PRN analgesia?
- A. Compare the client's pain scale rating with the prescribed dosing.
- B. Determine which prescription will have the quickest onset of action.
- C. Ask the client to choose which medication is needed for the pain.
- D. Document the client's report of pain in the electronic medical record.
Correct Answer: A
Rationale: When a postoperative client reports incisional pain and has two prescriptions for PRN analgesia, the nurse should first compare the client's pain scale rating with the prescribed dosing. This action ensures that the client receives the appropriate medication based on their pain level. Determining the onset of action or asking the client to choose the medication does not guarantee that the right medication is administered according to the pain intensity. Documenting the pain report is important but should not be the first action when deciding which medication to administer.
In the change of shift report, the nurse is told that a client has a stage 2 pressure ulcer. Which ulcer appearance is most likely to be observed?
- A. Shallow open ulcer with a red-pink wound bed.
- B. Intact skin with non-blanchable redness.
- C. Full-thickness tissue loss with visible fat.
- D. Full-thickness tissue loss with exposed bone, tendon, or muscle.
Correct Answer: A
Rationale: The correct answer is A: 'Shallow open ulcer with a red-pink wound bed.' Stage 2 pressure ulcers involve partial-thickness skin loss and typically appear as shallow open ulcers with a red-pink wound bed. Choice B describes a stage 1 ulcer, where the skin is intact but shows non-blanchable redness. Choice C describes a stage 3 ulcer, with full-thickness tissue loss exposing fat. Choice D is characteristic of a stage 4 ulcer, where there is full-thickness tissue loss exposing bone, tendon, or muscle. Therefore, option A best fits the description of a stage 2 pressure ulcer.
While changing the dressing of a client with a leg ulcer, the nurse observes a red, tender, and swollen wound at the site of the lesion. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?
- A. Neutrophil count.
- B. Hematocrit.
- C. Blood pH.
- D. Serum potassium and sodium.
Correct Answer: A
Rationale: The correct answer is A: Neutrophil count. Neutrophil count helps assess for infection, which is indicated by the redness, tenderness, and swelling of the wound. Elevated neutrophil count is a common sign of bacterial infection. Hematocrit (choice B) measures the proportion of blood volume that is occupied by red blood cells and is not directly related to wound infection. Blood pH (choice C) and serum potassium and sodium (choice D) are important for assessing acid-base balance and electrolyte levels but are not the primary indicators of wound infection.
When planning care for a client newly diagnosed with open-angle glaucoma, the nurse identifies a priority nursing problem of visual sensory/perceptual alterations. This problem is based on which etiology?
- A. Limited eye movement.
- B. Decreased peripheral vision.
- C. Blurred distance vision.
- D. Photosensitivity.
Correct Answer: B
Rationale: The correct answer is B: Decreased peripheral vision. In open-angle glaucoma, decreased peripheral vision is a characteristic symptom resulting from increased intraocular pressure. This visual impairment can lead to sensory/perceptual alterations. Choice A, limited eye movement, is not directly associated with the pathophysiology of open-angle glaucoma. Choice C, blurred distance vision, is more commonly seen in conditions like myopia or presbyopia. Choice D, photosensitivity, is not a typical manifestation of open-angle glaucoma and is more commonly associated with conditions like migraines or certain medications.