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The nurse is caring for an infant who has a prescription for amoxicillin 25 mg/kg/day in 2 divided doses. The client weighs 16.5 lb (7.5 kg). The nurse has amoxicillin oral suspension 125 mg/5 mL available. How many mL should the nurse administer to the client with each dose? Record your answer using 2 decimal places.
Correct Answer: 3.75 mL/dose
Rationale: Calculation: 7.5 kg × 25 mg/kg/day = 187.5 mg/day. Divided into 2 doses = 93.75 mg/dose. 125 mg/5 mL = 25 mg/mL. 93.75 mg ÷ 25 mg/mL = 3.75 mL/dose (A).
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The nurse is caring for a 12 year-old with an acute illness. Which of the following indicates the nurse understands common sibling reactions to hospitalization?
- A. Younger siblings adapt very well
- B. Visitation is helpful for both
- C. The siblings may enjoy privacy
- D. Those cared for at home cope better
Correct Answer: B
Rationale: Visitation is helpful for both. Contact with the ill child helps siblings understand hospitalization and maintain relationships.
Which of the following are violations of the Health Insurance Portability and Accountability Act regarding confidentiality of privileged health information? Select all that apply.
- A. A pregnancy result is given to a husband without the wife's permission
- B. The client overhears, through a privacy curtain, the nurse call report on someone
- C. The nurse calls the client by first and last name in the public waiting room
- D. The nurse tells the transporting tech that the client has breast cancer
- E. Unlicensed assistive personnel tell the discharged client, 'You take care now.'
Correct Answer: A,C,D
Rationale: Sharing pregnancy results without consent (A), calling names publicly (C), and disclosing a diagnosis to non-care staff (D) violate HIPAA. Overhearing through a curtain (B) is unintentional, and a general farewell (E) is not a violation.
The nurse monitoring a client with appendicitis will expect the client to give which description of the associated abdominal pain?
- A. A burning sensation; in the upper abdomen
- B. An 8 out of 10; on the left side below the belly button
- C. Excruciating; in the lower abdomen above the right hip
- D. Intermittent; in the abdomen and right shoulder
Correct Answer: C
Rationale: Appendicitis typically causes severe pain in the right lower quadrant (C). Upper abdominal burning (A) suggests gastritis, left-sided pain (B) is atypical, and shoulder pain (D) may indicate referred pain from other conditions.
The nursing assistant is caring for an adult who has a fractured femur and is in Buck's extension traction awaiting surgery. The nurse is observing the nursing assistant administer morning care. Which action by the nursing assistant needs correction?
- A. The nursing assistant leaves the weights in place while bathing the client.
- B. The nursing assistant turns the client's head to the side while administering oral hygiene.
- C. The nursing assistant makes the bed from head to foot.
- D. The nursing assistant turns the client on the side for back care.
Correct Answer: D
Rationale: Turning the client on the side disrupts Buck's traction alignment, which requires constant pull. Weights should stay in place, head turning is safe, and bed-making direction is irrelevant.
A parent has numerous questions regarding normal growth and development of a 10 month-old infant. Which of the following parameters is of most concern to the nurse?
- A. 50% increase in birth weight
- B. Head circumference greater than chest
- C. Crying when the parents leave
- D. Able to stand up briefly in play pen
Correct Answer: A
Rationale: 50% increase in birth weight. Birth weight should double by 6 months, indicating potential growth issues that require further evaluation.