Nokea
The nurse retrieves hydromorphone '4 mg/mL' from the electronic medication system, for a patient who is receiving hydromorphone 3 mg IM every 6 hours PRN for severe pain. How many mL should the nurse administer to the patient? (Enter the numerical value only. If rounding is required, round to the nearest tenth.)
Correct Answer: 0.8
Rationale: 3 mg ÷ 4 mg/mL = 0.75 mL, rounded to 0.8 mL.
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A family member is demonstrating wound care using sterile technique. Which action indicates to the nurse that additional teaching is needed?
- A. Uses normal saline to irrigate the wound.
- B. Cleans from less soiled to more soiled areas.
- C. Opens a sterile package towards the body.
- D. Places soiled dressing in a plastic bag.
Correct Answer: C
Rationale: Opening towards body risks contamination.
The nurse is performing a routine dressing change for a client with a stage 3 pressure injury that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?
- A. Leave the dressing off until consulting with the healthcare provider.
- B. Replace the gauze with a transparent dressing.
- C. Increase the frequency of the dressing changes.
- D. Apply a hydrocolloid gel dressing.
Correct Answer: D
Rationale: Hydrocolloid promotes moist healing.
The mother of a child born with Tetralogy of Fallot asks the nurse, 'Why did this happen to my baby? What did I do wrong?' Which response by the nurse is most helpful?
- A. Is there any particular reason why you think this is your fault?
- B. With surgery, your baby should have a full recovery.
- C. This must be a very difficult time for you.
- D. You did nothing wrong.
Correct Answer: C
Rationale: Empathy validates emotional distress.
While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?
- A. C-reactive protein level
- B. Serum potassium and sodium levels
- C. Neutrophil count
- D. Platelet count
Correct Answer: A
Rationale: CRP indicates inflammation, but neutrophils are more specific for infection.
A client with end-stage lung disease is dependent on a mechanical ventilator to sustain life. While the client's spouse is at the bedside, the client pleads in handwritten notes to have the endotracheal tube removed. The spouse tearfully agrees with the request. Which is the priority nursing intervention?
- A. Offer to contact the family's spiritual counselor to meet with the client and spouse.
- B. Discuss comfort measures with the client and family that will be available during withdrawal.
- C. Inform the healthcare provider of the client's desire to have life support withdrawn.
- D. Explain the actions that the healthcare team will follow for the removal of life support.
Correct Answer: C
Rationale: Notifying provider respects client autonomy.