Nokea
The nurse is caring for a client who has a prescription for albuterol 5 mg via nebulizer every 4 hours. The nurse has albuterol 2.5 mg/3 mL available. How many mL should the nurse administer to the client with each dose? Record your answer using a whole number.
Correct Answer: 6 mL/dose
Rationale: Albuterol 5 mg is needed, with 2.5 mg/3 mL available. Thus, 5 mg ÷ 2.5 mg × 3 mL = 6 mL per dose.
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The client has contact dermatitis from poison ivy. Which statement, if made by the client, indicates that he understands how to care for his condition?
- A. A hot bath should make the itching go away.'
- B. I will use a good strong soap when I wash the affected areas.'
- C. A cool wet cloth to the area should help.'
- D. Wearing wool socks will help my itchy feet.'
Correct Answer: C
Rationale: A cool wet cloth soothes itching and inflammation in contact dermatitis. Hot baths, strong soaps, or wool exacerbate irritation.
The nurse is reviewing the medical record of a 4-year-old client with failure to thrive. Which of the following risk factors likely contribute to the client's condition? Select all that apply.
- A. Child is the youngest of four children in the home
- B. One parent is incarcerated for spousal abuse
- C. One parent was diagnosed with anorexia nervosa prior to having children
- D. One parent works a full-time job outside the home
- E. Parents are concerned about not having enough money to buy food
Correct Answer: B,C,E
Rationale: FTT risk factors include parental incarceration causing family stress, a history of anorexia nervosa affecting feeding practices, and food insecurity . Being the youngest or a working parent are not direct risks.
The nurse is providing home care for a client who is visually impaired. What safety precaution is most appropriate for this client?
- A. Remove scatter rugs.
- B. Have hand rails in the bathroom.
- C. Have side rails up whenever the client is in bed.
- D. Have a bell to call for help.
Correct Answer: A
Rationale: Removing scatter rugs prevents tripping, the most effective safety measure for a visually impaired client at home.
The physician has ordered a sterile urine specimen to be collected from a client who has a Foley catheter. To obtain a sterile urine specimen, the nurse should:
- A. Use a luer lock syringe and withdraw from the bulb port.
- B. Disconnect the catheter from the drainage bag.
- C. Open the urine bag and remove the specimen.
- D. Use a syringe and withdraw from the catheter port.
Correct Answer: D
Rationale: Withdrawing from the catheter port with a syringe ensures a sterile specimen. Other methods risk contamination.
The nurse should monitor for which potential complication in a client receiving IV vancomycin and gentamicin?
- A. Blood in nasogastric tube drainage
- B. Decrease in red blood cell count
- C. Increase in serum creatinine level
- D. Onset of muscle aches and cramping
Correct Answer: C
Rationale: Vancomycin and gentamicin are nephrotoxic, so monitoring for increased serum creatinine is essential to detect kidney injury. GI bleeding , anemia , and muscle cramps are less directly related.