Nokea
The nurse is preparing to administer prescribed intravenous phenytoin to a client with epilepsy. Prior to starting the infusion, the nurse should
- A. establish continuous cardiac monitoring
- B. obtain the serum peak level prior to infusion
- C. initiate continuous electroencephalography (EEG) monitoring
- D. insert an indwelling urinary catheter
Correct Answer: A
Rationale: Phenytoin can cause cardiac arrhythmias, so continuous cardiac monitoring is necessary during infusion.
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The nurse is caring for a client who is prescribed IV heparin. The client is prescribed 12 units/kg/hr. The client weighs 92 kgs (202.4 lbs). The heparin is labeled with 25,000 units in 250 mL of D5W. How many mL/hr should the client receive?
Correct Answer: 11 mL/hr
Rationale: Calculation: 92 kg x 12 units/kg/hr = 1104 units/hr. Heparin concentration: 25,000 units/250 mL = 100 units/mL. 1104 units / 100 units/mL = 11.04 mL/hr, rounded to 11 mL/hr.
The nurse has taught a client who has been ordered a high in phosphorus diet about appropriate food choices. Which of the following food choices by the client would indicate a correct understanding of the teaching?
- A. Leafy greens
- B. Garlic
- C. Nuts
- D. Butter
- E. Turkey
Correct Answer: C, E
Rationale: Nuts and turkey are high in phosphorus, suitable for a high-phosphorus diet.
The nurse is teaching a group of nursing students about the five rights of delegation. The nurse is correct to include that this involves the right
- A. intention
- B. alternative
- C. assessment
- D. task
Correct Answer: D
Rationale: The five rights of delegation include the right task, ensuring appropriate delegation.
The nurse is triaging a child with suspected impetigo. Which action should the nurse take?
- A. Initiate droplet precautions
- B. Set up a decontamination room
- C. Use a disposable blood pressure cuff
- D. Initiate contact precautions
- E. Apply sterile gloves while examining the client
Correct Answer: D, E
Rationale: Impetigo requires contact precautions and sterile gloves to prevent spread during examination.
The nurse assists a client with cystic fibrosis in picking out items on a menu. It will indicate effective teaching if the client selects meals that are
- A. high in fat
- B. low in sodium
- C. low in calories
- D. low in protein
Correct Answer: A
Rationale: High-fat meals provide necessary calories for cystic fibrosis patients with high energy needs.