Nokea
The nurse is preparing to administer an anticholinergic medication to a client with irritable bowel syndrome. Which of the following findings would require follow-up prior to administering the medication?
- A. bladder scan that shows 650 mL of urine after voiding
- B. history of age-related macular degeneration
- C. frequent loose stools in the past 24 hours
- D. reports of fatigue and drowsiness
Correct Answer: A
Rationale: Anticholinergics can worsen urinary retention, so 650 mL post-void residual (A) requires follow-up. Macular degeneration (B), loose stools (C), and fatigue (D) are not contraindications.
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Which of the following situations is most likely to produce sepsis in the neonate?
- A. Maternal diabetes
- B. Prolonged rupture of membranes
- C. Cesarean delivery
- D. Precipitous vaginal birth
Correct Answer: B
Rationale: Prolonged rupture of membranes. Premature rupture of the membranes (PROM) is a leading cause of newborn sepsis. After 12-24 hours of leaking fluid, measures are taken to reduce the risk to mother and the fetus/newborn.
The nurse's neighbor calls the nurse and asks for assistance with her child who developed a nosebleed after being hit in the nose by a ball. What should the nurse recommend to the neighbor?
- A. Pinch the child's nose and bend the head forward.
- B. Pinch the child's nose and bend the head backward.
- C. Put ice on the nose and call 911 immediately.
- D. Stuff cotton up both nostrils and bend the head backward.
Correct Answer: A
Rationale: Pinching the nose and leaning forward compresses the bleeding site and prevents blood swallowing, effectively managing a nosebleed caused by trauma.
The practical nurse is reinforcing discharge teaching to a client seen for treatment of a second episode of acute gout. Which instructions should be included to prevent future exacerbations? Select all that apply.
- A. Achieve and maintain a healthy weight
- B. Avoid diet sodas
- C. Avoid foods containing protein
- D. Drink plenty of fluids
- E. Restrict alcohol consumption
Correct Answer: A,D,E
Rationale: Healthy weight (A), hydration (D), and limiting alcohol (E) reduce uric acid levels and gout risk. Diet sodas (B) are not directly linked, and avoiding all protein (C) is unnecessary.
The nurse is caring for a client who is experiencing the cardiac rhythm in the ECG strip shown below. The nurse should recognize that the client is experiencing
- A. atrial flutter
- B. sinus bradycardia
- C. normal sinus rhythm
- D. premature atrial contractions
Correct Answer: C
Rationale: Without the ECG strip, normal sinus rhythm (C) is assumed for a stable client, characterized by regular P waves, QRS complexes, and a rate of 60-100 bpm. Other options indicate abnormal rhythms.
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).