Nokea
The nurse calculates the amount of an antibiotic for injection to be given to an infant. The amount of medication to be administered is 1.25 mL. The nurse should:
- A. Divide the amount into two injections and administer in each vastus lateralis muscle
- B. Give the medication in one injection in the dorsogluteal muscle
- C. Divide the amount in two injections and give one in the ventrogluteal muscle and one in the vastus lateralis muscle
- D. Give the medication in one injection in the ventrogluteal muscle
Correct Answer: A
Rationale: For infants, volumes greater than 1 mL should be divided and administered in separate sites, such as each vastus lateralis, to reduce discomfort and ensure absorption.
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The nurse is assessing an ECG strip of a 42-year-old client and finds a regular rate greater than 100, a normal QRS complex, a normal P wave in front of each QRS, a PR interval between 0.12 and 0.20 seconds, and a P: QRS ratio of 1:1. What is the nurse's interpretation of this rhythm?
- A. Premature atrial complex
- B. Sinus tachycardia
- C. Atrial flutter
- D. Supraventricular tachycardia
Correct Answer: B
Rationale: A regular rate >100 with normal P waves, QRS complexes, and PR interval indicates sinus tachycardia, a common response to stress, fever, or hypoxia.
The nurse in the outpatient clinic teaches the mother of a 10-year-old boy with asthma how to prevent future asthmatic attacks. The nurse would be MOST concerned if the mother made which of the following statements?
- A. My son plays the tuba in the grade school band.
- B. My son loves to help his dad rake leaves.
- C. My son participates in after-school activities three days a week.
- D. My son walks one mile to school every day with his friends.
Correct Answer: B
Rationale: main cause of asthma is inhaled allergens (animal dander, mold, pollen, dust), would expose child to pollen and dust from leaves
A client with $B$ positive blood is scheduled for a transfusion of whole blood. Which finding requires nursing intervention?
- A. The available blood has been banked for 2 weeks.
- B. The blood available for transfusion is Rh negative.
- C. The client has a peripheral IV of D5 $1 / 2$ normal saline.
- D. The blood available for transfusion is type 0 positive.
Correct Answer: B
Rationale: Transfusing Rh-negative blood to an Rh-positive client can cause incompatibility reactions, requiring intervention to ensure Rh compatibility.
The nurse has assessed the assigned group of clients. Which client would the nurse identify as being at the greatest risk for alterations in sensory perception?
- A. a client in a halo vest following an automobile accident
- B. a child with severe autism who is having a tonsillectomy
- C. a teenager who broke her leg during cheerleader practice
- D. a schoolteacher who was hospitalized for shortness of breath
Correct Answer: B
Rationale: Severe autism often involves sensory processing issues, increasing risk for sensory perception alterations, especially during stressful procedures like surgery.
The nurse is caring for a client who is postoperative day 1 following a laparoscopic appendectomy. The client reports shoulder pain. Which of the following actions should the nurse take?
- A. Administer an analgesic as ordered.
- B. Notify the physician immediately.
- C. Explain that this is referred pain from residual gas.
- D. Place the client in a prone position.
Correct Answer: C
Rationale: shoulder pain after laparoscopic surgery is often due to referred pain from residual carbon dioxide used during the procedure