Nokea
The nurse needs to withdraw a prescribed 7000 units from the medication vial for administration. For a safe dose of medication how many milliliters should the nurse withdraw? Fill in the blank and record your answer using one decimal place.
Correct Answer: 1.4
Rationale: Use the medication calculation formula. Since this is a fill-in-the-blank question, the answer is 1.4 mL,
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The nurse is caring for a child with a diagnosis of intussusception. During care, the child passes a formed brown stool. Which action is most appropriate for the nurse to take at this time?
- A. Note the child's physical symptoms.
- B. Prepare the child for hydrostatic reduction.
- C. Prepare the child and parents for the possibility of surgery.
- D. Report the passage of a normal brown stool to the primary health care provider.
Correct Answer: D
Rationale: Intussusception is the telescoping of one portion of the bowel into another portion. Passage of a normally formed brown stool usually indicates that the intussusception has reduced itself. This is immediately reported to the primary health care provider, who may choose to alter the diagnostic or therapeutic plan of care. Although the nurse would note the child's physical symptoms, based on the data in the question, option 4 is the appropriate action. Hydrostatic reduction and surgery may not be necessary.
A client receiving chemotherapy has an extremely low white blood cell count and is immediately placed on neutropenic precautions that include a low-bacteria diet. Which food items is the client now allowed to consume? Select all that apply.
- A. Raw celery
- B. Fresh apple
- C. Italian bread
- D. Tossed salad
- E. Baked chicken
- F. Well-cooked cheeseburger
Correct Answer: C,E,F
Rationale: An extremely low white blood cell count places the client at risk for infection. In the immunocompromised client, a low-bacteria diet is implemented. Italian bread, baked chicken, and a well-done cheeseburger are acceptable to consume because all products are thoroughly cooked. The client avoids eating fresh fruits and vegetables. Fresh fruits and vegetables harbor organisms and place the client at risk for infection.
Which clinical situation should the nurse identify as an example of slander?
- A. The primary health care provider tells a client that the nurse 'does not know anything.'
- B. The nurse tells a client that a nasogastric tube will be inserted if the client continues to refuse to eat.
- C. The nurse restrains a client at bedtime because the client gets up during the night and wanders around.
- D. The laboratory technician restrains the arm of a client refusing to have blood drawn so that the specimen can be obtained.
Correct Answer: A
Rationale: Defamation takes place when a falsehood is said (slander) or written (libel) about a person that results in injury to that person's good name and reputation. Battery involves offensive touching or the use of force by a perpetrator without the permission of the victim. An assault occurs when a person puts another person in fear of a harmful or offensive act.
The nurse monitors a client who has been diagnosed with brain death as a result of a severe head injury and is a potential organ donor. Which client assessment data should indicate to the nurse that the standard of care as an organ donor has been maintained?
- A. Urine output: 100mL} / \mathrm{hr
- B. \mathrm{pH of arterial blood: 7.32
- C. Capillary refill: 5 seconds
- D. Blood pressure: 90 / 48mmHg
Correct Answer: A
Rationale: Urine output at 100mL per hour indicates adequate renal perfusion and indicates that care standards as an organ donor are maintained. Clinical indicators of care below the standard include a \mathrm{pH of 7.32, indicating acidosis; capillary refill at 5 seconds, which is too slow; and hypotension, indicating an inadequate cardiac output. Guidelines that may be used and are helpful in determining organ viability are the 'rule of 100s ' in which the systolic blood pressure is maintained at 100mmHg , urine output at 100mL per hour, heart rate at 100 beats per minute, and \mathrm{PaO}_2 at 100mmHg .
Which interventions should the nurse perform when inserting an indwelling urinary catheter in order to maintain both the integrity of the catheter and the client's safety? Select all that apply.
- A. Use strict aseptic technique.
- B. Place the drainage bag lower than the bladder level.
- C. Inflate the balloon with 4 to 5 mL beyond its capacity.
- D. Swab the urinary catheter with sterile water before inserting.
- E. Advance the catheter 1 to 2 inches after urine appears in the tubing.
Correct Answer: A,B,E
Rationale: The nurse would use strict aseptic technique to insert the catheter. The drainage bag is placed lower than bladder level to ensure drainage, prevent retrograde flow of urine, and reduce the risk of infection. Advancing the catheter 1 to 2 inches beyond the point where the flow of urine is first noted is also good practice because this ensures that the catheter balloon is completely in the bladder before it is inflated. The nurse risks rupturing the catheter's balloon by overinflating it; therefore, the nurse inflates the balloon with the specified volume for the catheter because inflating the balloon with 4 to 5 mL beyond its capacity is unsafe. The urinary catheter is sterile, so it is inappropriate and unnecessary to swab it with sterile water before inserting.