Nokea
The nurse is to administer midazolam (Versed) 2.5 mg. The medication is available in a 5 mg/mL vial. The nurse should administer ___ mL.
Correct Answer: 0.5
Rationale: To administer 2.5 mg from a 5 mg/mL vial, calculate: 2.5 mg ÷ 5 mg/mL = 0.5 mL. This is a calculation question, not multiple-choice, but included as per instructions.
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The nurse is teaching a client about isoniazid (INH). Which of the following statements should the nurse include?
- A. This medication may turn your secretions reddish/orange.
- B. Yellowing of your eyes is a normal side-effect.
- C. A B-complex vitamin should be taken to help with the neuropathy.
- D. This medication will need to be taken every day for at least one week.
Correct Answer: C
Rationale: Isoniazid (INH) can cause peripheral neuropathy, and a B-complex vitamin (especially vitamin B6) is often recommended to help prevent or manage this side effect. Choice A is incorrect because reddish/orange secretions are associated with rifampin, not INH. Choice B is incorrect because yellowing of the eyes (jaundice) is a sign of hepatotoxicity, a serious adverse effect, not a normal side effect. Choice D is incorrect because INH treatment for tuberculosis typically lasts 6-9 months, not just one week.
A middle-aged man collapses in the emergency department waiting room. The triage nurse should first:
- A. Gently shake the victim and ask him to state his name.
- B. Perform the chin-tilt to open the victim's airway.
- C. Feel for any air movement from the victim's nose or mouth.
- D. Watch the victim's chest for respirations.
Correct Answer: A
Rationale: The first step in assessing an unresponsive patient is to check for responsiveness by gently shaking and calling out to the victim, per AHA guidelines, to determine if CPR or other interventions are needed.
A client with neutropenia has an absolute neutrophil count of 900. What is the client's risk of infection?
- A. Normal risk.
- B. Moderate risk.
- C. High risk.
- D. Extremely high risk.
Correct Answer: C
Rationale: An absolute neutrophil count (ANC) of 900 indicates moderate to severe neutropenia (ANC <1,000). This places the client at high risk for infection, as neutrophils are critical for fighting pathogens. Normal risk is ANC >1,500, and extremely high risk is ANC <200.
A client had a repair of a thoracoabdominal aneurysm 2 days ago. Which of the following findings should the nurse consider unexpected and report to the physician immediately? The client has:
- A. Abdominal pain at 5 on a scale of 0 to 10 for the last 2 days
- B. Heart rate of 100 beats per minute after ambulating 200 feet
- C. Urine output of 2,000 mL in 24 hours
- D. Weakness and numbness in the lower extremities
Correct Answer: D
Rationale: Weakness and numbness in the lower extremities post-thoracoabdominal aneurysm repair suggest spinal cord ischemia or graft-related complications, requiring immediate reporting. Persistent pain, elevated heart rate post-ambulation, and normal urine output are expected or less urgent.
The client asks the nurse to explain what it means that his Hodgkin's disease is diagnosed at stage 1A. Which of the following describes the involvement of the disease?
- A. Involvement of a single lymph node.
- B. Involvement of two or more lymph nodes on the same side of the diaphragm.
- C. Involvement of lymph node regions on both sides of the diaphragm.
- D. Diffuse disease of one or more extralymphatic organs.
Correct Answer: A
Rationale: Stage 1A Hodgkin's disease indicates involvement of a single lymph node region without B symptoms (fever, night sweats, weight loss). Higher stages involve multiple nodes or extralymphatic sites.