Nokea
The nurse needs to administer 7.5 mg of a medication intramuscularly. The medication label reads '10 mg/mL.' How much medication should the nurse prepare to administer? Fill in the blank.
Correct Answer: 0.75
Rationale: Use the following formula to calculate the medication dose: Desired / Available × Volume = mL per dose. 7.5 mg / 10 mg × 1 mL = 0.75 mL.
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A client diagnosed with heart failure is receiving furosemide and digoxin daily. When the nurse enters the room to administer the morning doses, the client reports anorexia, nausea, and yellow vision. Which intervention should the nurse implement first?
- A. Administer the medications.
- B. Contact the primary health care provider.
- C. Check the morning serum digoxin level.
- D. Check the morning serum potassium level.
Correct Answer: C
Rationale: The nurse should check the result of the digoxin level that was drawn because the client's symptoms are compatible with digoxin toxicity. A low potassium level may contribute to digoxin toxicity, so checking the serum potassium level may give useful additional information, but the digoxin level should be checked first. The medications should be withheld until both levels are known. If the digoxin level is elevated or the potassium level is not within the normal range, then the primary health care provider should be notified. If the morning digoxin level is within the therapeutic range, then the client's complaints are unrelated to the digoxin.
The nurse is caring for an infant after a pyloromyotomy is performed to treat hypertrophic pyloric stenosis. In which position should the nurse place the infant after surgery?
- A. Flat on the operative side
- B. Flat on the unoperative side
- C. Prone with the head of the bed elevated
- D. Supine with the head of the bed elevated
Correct Answer: C
Rationale: After pyloromyotomy, the head of the bed is elevated, and the infant is placed prone to reduce the risk of aspiration. Based on this information, the remaining options are incorrect positions after this type of surgery. The surgeon's prescriptions for positioning should always be followed.
A client tells the clinic nurse that her skin is very dry and irritated. Which product should the nurse suggest that the client apply to the dry skin?
- A. Myoflex
- B. Aspercreme
- C. Topical emollient
- D. Acetic acid solution
Correct Answer: C
Rationale: A topical emollient is used for dry, cracked, and irritated skin. Aspercreme and Myoflex are used to treat muscular aches. Acetic acid solution is used for irrigating, cleansing, and packing wounds infected with Pseudomonas aeruginosa.
Which is the most important laboratory result for the nurse to present to the primary health care provider on a client who is receiving total parenteral nutrition (TPN)?
- A. White blood cell count
- B. Serum electrolyte levels
- C. Arterial blood gas levels
- D. Hemoglobin and hematocrit levels
Correct Answer: B
Rationale: Serum electrolyte levels are critical to monitor in a client receiving TPN because TPN solutions contain high concentrations of glucose and electrolytes, which can lead to imbalances such as hyperkalemia, hypokalemia, or hyponatremia. These imbalances can cause serious complications, including cardiac dysrhythmias or neurological issues. While white blood cell count, arterial blood gas levels, and hemoglobin and hematocrit levels are important, they are not as directly related to the immediate risks associated with TPN administration as electrolyte levels.
The nurse is caring for a client who is scheduled an arthrogram involving the use of a contrast medium. Which action by the nurse is the priority?
- A. Determining the presence of client allergies
- B. Asking if the client has any last-minute questions
- C. Telling the client to try to void before leaving the unit
- D. Emphasizing to the client the importance of remaining still during the procedure
Correct Answer: A
Rationale: Because of the risk of allergy to contrast medium, the nurse places the highest priority on assessing whether the client has an allergy to iodine or shellfish. The nurse also reinforces information about the test and reminds the client about the need to remain still during the procedure. It is helpful to have the client void before the procedure for comfort.