Nokea
The nurse is preparing to administer phenytoin (Dilantin), 100 mg intravenous push, to the client with a head injury who has an IV of D5W at 50 mL/hr. Which intervention should the nurse implement?
- A. Flush the IV tubing before and after with normal saline.
- B. Administer the medication if the Dilantin level is 22 mcg/mL.
- C. Push the Dilantin intravenously slowly over five (5) minutes.
- D. Expect the intravenous tubing to turn cloudy when infusing medication.
Correct Answer: A
Rationale: Phenytoin is incompatible with D5W; saline flush prevents precipitation. Level of 22 mcg/mL is toxic, slow push is correct but not primary, and cloudiness is avoidable.
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The nurse is caring for a 10 year-old client who will be placed on heparin therapy. Which assessment is critical for the nurse to make before initiating therapy?
- A. Vital signs
- B. Weight
- C. Lung sounds
- D. Skin turgor
Correct Answer: B
Rationale: Weight. Check the client's weight because dosage is calculated on the basis of weight.
A young adult, 20 years old, who is hospitalized for the first time with schizophrenia, is receiving chlorpromazine (Thorazine) 75 mg PO tid. The client is to go home for a weekend pass. Which statement that the client makes indicates a need for nursing intervention?
- A. I won't drink any alcohol this weekend.
- B. It will be good to taste home-cooked food again.
- C. We plan to go dancing.
- D. I'm looking forward to a relaxing weekend at the beach.
Correct Answer: C
Rationale: Chlorpromazine causes orthostatic hypotension and photosensitivity. Dancing may exacerbate hypotension, requiring caution and education.
The client is experiencing supraventricular tachycardia (SVT). Which antidysrhythmic medication should the nurse prepare to administer?
- A. Atropine.
- B. Amiodarone.
- C. Adenosine.
- D. Dobutamine.
Correct Answer: C
Rationale: Adenosine is first-line for SVT, rapidly terminating the arrhythmia, per ACLS guidelines. Other drugs are used for different rhythms.
The client diagnosed with adult-onset asthma is being discharged. Which medication would the nurse expect the health-care provider to prescribe?
- A. A nonsteroidal anti-inflammatory medication.
- B. An antihistamine medication.
- C. An angiotensin-converting enzyme inhibitor.
- D. A proton pump inhibitor.
Correct Answer: None
Rationale: Asthma typically requires bronchodilators (e.g., albuterol) or steroids, not listed. None of the options are standard asthma treatments.
The 54-year-old female client with severe menopausal symptoms is prescribed hormone replacement therapy (HRT). Which secondary health screening activity should the nurse recommend for HRT?
- A. A Pap smear every six (6) months.
- B. A yearly mammogram.
- C. A bone density test every three (3) months.
- D. A serum calcium level monthly.
Correct Answer: B
Rationale: HRT increases breast cancer risk; yearly mammograms are recommended for screening, per ACOG guidelines. Other tests are not standard.