Nokea
The nurse is caring for a client with a history of deep vein thrombosis (DVT). Which of the following interventions should be included in the plan of care?
- A. Encourage early ambulation.
- B. Apply cold compresses to the affected leg.
- C. Elevate the affected leg.
- D. Massage the affected leg.
Correct Answer: A, C
Rationale: Early ambulation and leg elevation promote venous return and prevent clot progression. Cold compresses and massage are contraindicated.
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The nurse has an order to administer ampicillin (Omnipen) 250 mg I.M. After reconstituting the ampicillin with sterile water for injection, the solution available is 500 mg/mL. How many milliliters should the nurse administer?
- A. 0.5 mL.
- B. 1 mL.
- C. 2 mL.
- D. 1.5 mL.
Correct Answer: A
Rationale: To administer 250 mg from a 500 mg/mL solution, the calculation is 250 mg / 500 mg/mL = 0.5 mL.
When teaching a group of parents about the potential for febrile seizures in children, which of the following facts should the nurse include?
- A. The exact cause is known.
- B. The seizures occur as the fever rises.
- C. Children older than age 3 are most at risk.
- D. These seizures commonly occur after immunization administration.
Correct Answer: B
Rationale: Febrile seizures typically occur as the fever rises rapidly in young children (usually under age 5), not specifically after immunizations or in older children.
A client with a burn injury is prescribed silver sulfadiazine. What should the nurse monitor for?
- A. Hypokalemia.
- B. Leukopenia.
- C. Hyperglycemia.
- D. Hypertension.
Correct Answer: B
Rationale: Silver sulfadiazine can cause leukopenia, so monitoring white blood cell counts is essential.
A client with a history of gastroesophageal reflux disease (GERD) is prescribed omeprazole (Prilosec). The nurse should instruct the client to:
- A. Take the medication before meals.
- B. Take the medication with meals.
- C. Take the medication at bedtime.
- D. Stop the medication if heartburn resolves.
Correct Answer: A
Rationale: Omeprazole is most effective when taken before meals to reduce acid production.
The nurse provides home care instructions to a client who is taking lithium carbonate. Which statement by the client indicates a need for further teaching?
- A. I need to take the lithium with meals.
- B. My blood levels must be monitored very closely.
- C. I need to decrease my salt and fluid intake while taking the lithium.
- D. I need to withhold the medication if I have excessive diarrhea or vomiting.
Correct Answer: C
Rationale: A normal diet and normal salt and fluid intake (1500 to 3000 mL per day) should be maintained because lithium decreases sodium reabsorption by the renal tubules, which could cause sodium depletion. A low-sodium intake causes a relative increase in lithium retention and could lead to toxicity. Lithium is irritating to the gastric mucosa; therefore, lithium should be taken with meals. Because therapeutic and toxic dosage ranges are so close, lithium blood levels must be monitored very closely: more frequently at first and then once every several months after that. The client should be instructed to withhold the medication if excessive diarrhea, vomiting, or diaphoresis occurs, and inform the primary health care provider if any of these problems arise.