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The nurse receives a prescription to administer dopamine at 5 mcg/kg/min. The nurse has a bag labeled with dopamine 200 mg in 250 mL of D5W on hand. The client weighs 81.81 kg (179.98 lbs). How many mL/hr will the nurse administer?
Correct Answer: 31 mL/hr
Rationale: Calculation: 81.81 kg x 5 mcg/kg/min = 409.05 mcg/min x 60 = 24,543 mcg/hr = 24.543 mg/hr. Dopamine: 200 mg/250 mL = 0.8 mg/mL. 24.543 / 0.8 = 30.68 mL/hr, rounded to 31 mL/hr.
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The nurse is caring for a client who has been prescribed sertraline. The nurse understands that this medication is prescribed for which of the following conditions?
- A. Major Depressive Disorder
- B. Attention Deficit Hyperactivity Disorder
- C. Obsessive-Compulsive Disorder
- D. Generalized Anxiety Disorder
- E. Bipolar Disorder
Correct Answer: A, C, D
Rationale: Sertraline, an SSRI, is indicated for Major Depressive Disorder, Obsessive-Compulsive Disorder, and Generalized Anxiety Disorder, but not for ADHD or Bipolar Disorder.
The nurse observes a parent swaddling their infant with an unrepaired omphalocele. Which of the following statements would be appropriate?
- A. Stop! You will kill your baby.
- B. That is a nice, tight swaddle. It will help soothe your new baby.
- C. May I help you? We must be careful with the baby's intestines since we do not want the swaddle to push them back inside.
- D. Swaddling is not allowed for these babies; please stop.
Correct Answer: C
Rationale: This statement educates the parent gently, explaining the risk to the omphalocele without alarming them.
While preparing to change the dressing of a female patient with end-stage renal disease, the nurse notices that the patient's son is silently holding her hand and praying. Which of the following should be the nurse's initial action?
- A. Continue preparing for the procedure in the room.
- B. Notify the chaplain.
- C. Leave the room quietly and come back after 15 minutes to change the client's dressing.
- D. Ask the son if he wants the nurse to join in prayer.
Correct Answer: C
Rationale: Respecting the spiritual moment, leaving the room quietly allows privacy and maintains dignity.
The nurse is caring for a pregnant client at 28 weeks' gestation who presents to the emergency department with signs of preeclampsia. The primary healthcare provider (PHCP) orders magnesium sulfate. What potential complication should the nurse closely monitor for during magnesium sulfate administration?
- A. Pulmonary edema
- B. Hyperglycemia
- C. Hyporeflexia
- D. Increased fetal movement
Correct Answer: C
Rationale: Hyporeflexia is a sign of magnesium toxicity, a critical complication to monitor during administration.
The following scenario applies to the next 1 items
The nurse in the emergency department (ED) is caring for a 70-year-old client.
Item 1 of 1
Nurses' Notes
1100: Client was brought into the ED via emergency medical services (EMS) after he was found wandering the streets and completely disoriented. He was carrying a wallet and identification. His previous medical history was obtained from medical records—history of atrial fibrillation and diabetes mellitus (type two). On assessment, the client is lethargic, disoriented, and mumbling incoherent words. Breathing appears slightly labored, and wheezes with scattered rhonchi are noted in the bilateral lung fields—productive cough with a large amount of mucous. Skin is hot to touch, pale in tone; pulses 2+ and irregular. The client has an unkempt appearance and is malodorous. Peripheral venous access device (VAD) placed in right forearm. Vital signs: T 102° F (38.9° C), P 92, RR 24, BP 144/89, pulse oximetry reading 91% on room air. Orders received from the physician.
The nurse reviews the physician's orders and plans implementation. For each potential nursing action, click to specify whether the action is a high priority or a low priority.
- A. Educate the client on using the incentive spirometer
- B. Perform a head-to-toe skin assessment
- C. Notify radiology to obtain the portable chest radiograph (x-ray)
- D. Administer albuterol via nebulizer
- E. Apply supplemental oxygen via nasal cannula
- F. Collect ordered laboratory work (CBC, CMP, blood cultures)
- G. Perform admission medication reconciliation
Correct Answer: C, D, E, F (high priority); A, B, G (low priority)
Rationale: High priority: Chest x-ray, albuterol, oxygen, and labs address acute respiratory distress and infection. Low priority: Spirometer education, skin assessment, and medication reconciliation can be delayed.