Nokea
The nurse has received a prescription from the health care provider to administer 94 mg of methylprednisolone via IV push. The available vial contains 125 mg in 2 mL. Select the syringe containing the appropriate amount of medication to be administered.
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: C
Rationale: Calculate: 94 mg ÷ 125 mg/2 mL = 1.504 mL. Syringe 3 (typically 1.5 mL) is closest. Syringes 1, 2, and 4 are not specified but assumed incorrect volumes.
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The nurse is caring for a client who is receiving an intravenous infusion. Which finding would indicate that the client's IV has infiltrated?
- A. The client's arm is red and warm to the touch.
- B. The IV is running faster than the desired rate.
- C. The area around the infusion site is pale and cool to the touch.
- D. The client complains of severe pain up and down the arm.
Correct Answer: C
Rationale: Infiltration causes pale, cool skin around the IV site due to fluid leakage into tissues. Redness, fast infusion, or radiating pain suggest other issues.
A client who is pregnant comes to the clinic for a first visit. The nurse gathers data about her obstetric history, which includes 3 year-old twins at home and a miscarriage 10 years ago. She is 8 weeks pregnant. Which description of her obstetric history is written correctly?
- A. Gravida 4 para 2
- B. Gravida 2 para 1
- C. Gravida 3 para 1
- D. Gravida 3 para 2
Correct Answer: C
Rationale: Gravida 3 para 1. Gravida is the number of pregnancies and Parity is the number of pregnancies that reach viability (not the number of fetuses). Thus, for this woman, she is now pregnant, had 2 prior pregnancies, and 1 viable birth (twins).
A Spanish-speaking client is admitted for a small bowel obstruction. The surgeon explains to the client's child, who speaks both Spanish and English, that an exploratory laparotomy is needed to determine the cause of the obstruction and that possible causes include intestinal adhesions and ovarian or colon cancer. The surgeon asks the child to translate this information for the client and assist with translating the consent form. Which action by the nurse would be most appropriate?
- A. Act as a witness for the informed consent process
- B. Reinforce information about what the client can expect
- C. Report the surgeon to the ethics board for using an inappropriate consent process
- D. Talk to the surgeon privately about using a trained Spanish-language medical interpreter
Correct Answer: D
Rationale: Using a trained interpreter ensures accurate, unbiased communication. Witnessing or reinforcing perpetuates the error, and reporting is premature.
The nurse is caring for a 7-year-old client with acute glomerulonephritis. Which of the following is a priority for the nurse to monitor?
- A. Blood pressure
- B. Hematuria
- C. Peripheral edema
- D. Serum lipid levels
Correct Answer: A
Rationale: Hypertension is a priority in glomerulonephritis due to fluid retention, risking complications. Hematuria , edema , and lipids are monitored but less urgent.
A client receives an injection of botulinum toxin type A for facial and neck rejuvenation. The nurse should monitor for which complication of this procedure?
- A. Abdominal rigidity and diarrhea
- B. Back pain and urge incontinence
- C. Difficulty swallowing and breathing
- D. Difficulty walking and hand tremor
Correct Answer: C
Rationale: Botulinum toxin can cause muscle weakness, leading to dysphagia and respiratory issues . Abdominal , urinary , or motor symptoms are not typical.