Nokea
The healthcare provider prescribes streptomycin 200 mg IM every 12 hours. The vial is labeled, 'Streptomycin 1 gram/25 mL'. How many milliliters should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)
Correct Answer: 5
Rationale: 200 mg ÷ (1000 mg/25 mL) = 5 mL.
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When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?
- A. Assess strength of deep tendon reflexes.
- B. Determine apical pulse rate and rhythm.
- C. Observe color and amount of urine.
- D. Compare muscle strength bilaterally.
Correct Answer: B
Rationale: Hyperkalemia risks arrhythmias; cardiac monitoring is critical.
A family requested a visit from a hospice nurse as they think the client appears to be nearing the end of life. The nurse assesses the client. Which of the following signs indicate that the client is near death?
- A. Decreased muscle tone, relaxed jaw muscles, sagging mouth.
- B. Urine output is clear yellow.
- C. Altered breathing (apnea, labored or irregular breathing, Cheyne-Stokes pattern).
- D. Congestion/increased pulmonary secretions; noisy respirations (death rattle).
Correct Answer: A,C,D
Rationale: Muscle tone, breathing, and secretions indicate nearing death.
A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?
- A. Active bowel sounds in the lower right quadrant.
- B. Contraction of the left pupil when light shines in the right eye.
- C. Basilar lung sounds that are diminished in the left lung.
- D. Capillary refill of 2 seconds in the lower right foot.
Correct Answer: C
Rationale: Abnormal findings are documented.
A 16-year-old emancipated client is being seen in the emergency department following a minor automobile accident. The client’s parents arrive and are asking about the client’s laboratory results. Which response is best for the nurse to provide?
- A. The healthcare provider will share this information with you.'
- B. I’m sorry, but your child’s medical information is none of your business.'
- C. I can give you those results as soon as I get them back from the laboratory.'
- D. I can only give medical information to your child because they are legally an adult.'
Correct Answer: D
Rationale: Emancipated minors have autonomy.
What times should the nurse measure vital signs? Select all that apply.
- A. 1500
- B. 1600
- C. 1800
- D. 1000
- E. 1200
Correct Answer: A,B,C,G,H
Rationale: Times align with fever monitoring.