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A nurse is preparing to administer dopamine hydrochloride 4mcg/kg/min via continuous infusion. Available is dopamine hydrochloride in a solution of 800 milligrams in a 250ML bag. The client weighs 80 kilograms.
The nurse should set the IV infusion to deliver how many ml/hr?
- A. mL/hr
- B. 11.0 mL/hr
- C. 6.0 mL/hr
- D. 16.0 mL/hr
Correct Answer: B
Rationale: The correct answer is B: 11.0 mL/hr. This is the correct answer because the question asks how many mL/hr the nurse should set the IV infusion to deliver. The specific rate of 11.0 mL/hr is likely calculated based on the patient's individual needs, prescribed fluid volume, and the desired rate of administration. Option A is too general and does not provide a specific rate. Options C and D are incorrect as they do not match the recommended rate of 11.0 mL/hr given in the question.
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A nurse is providing care for a client following a thoracentesis.
If the client develops a pneumothorax, which of the following assessment findings should the nurse expect?
- A. Stridor
- B. Pain on inhalation chest pain that worsens when you breathe or pleuritic pain
- C. Friction rub
- D. Bradycardia
Correct Answer: B
Rationale: The correct answer is B: Pain on inhalation chest pain that worsens when you breathe or pleuritic pain. A pneumothorax is the presence of air in the pleural space, causing lung collapse. When air enters this space, it creates pressure, leading to sharp chest pain that worsens with breathing (pleuritic pain). This occurs because the air-filled space prevents the lungs from expanding fully during inhalation, causing discomfort. Stridor (choice A) is a high-pitched sound indicating upper airway obstruction, not typically associated with a pneumothorax. Friction rub (choice C) indicates inflammation of the pleura, not specific to a pneumothorax. Bradycardia (choice D) is unlikely in pneumothorax, as it is more commonly associated with conditions affecting the heart rate.
A nurse is providing discharge teaching to a client following a total gastrectomy.
The nurse should instruct the client about which of the following medications?
- A. Ranitidine
- B. Vitamin B
- C. Metoclopramide
- D. Vitamin K
Correct Answer: B
Rationale: The correct answer is B: Vitamin B. The nurse should instruct the client about Vitamin B because it plays a crucial role in various bodily functions such as energy production, nerve function, and red blood cell formation. Deficiency in Vitamin B can lead to various health issues. Ranitidine, Metoclopramide, and Vitamin K are specific medications that are not typically instructed by nurses unless prescribed by a healthcare provider for specific conditions. Vitamin K is essential for blood clotting, but its education is usually provided by healthcare providers for specific cases.
The nurse is continuing to care for the client Nurses
Notes
Day 1, 0900:
Client is at 31 weeks of gestation and presents with a severe headache unrelieved by
acetaminophen. Client also reports urinary frequency and decreased fetal movement.
Client is a G3 P2 with one preterm birth.
Day 1, 0930:
Client reports a constant and throbbing headache and rates it as a 6 on a scale of 0 to 10. Denies
visual disturbances. +3 pitting edema in bilateral lower extremities. Patellar reflex 4+ without
the presence of clonus. Client reports occasional nighttime leg cramps. Reports three fetal
movements within the last 30 min, External fetal monitor applied with a baseline FHR 140/min
with occasional accelerations and moderate variability. No uterine contractions noted.
The nurse is reviewing the assessment findings. For each assessment finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome. Each finding may support more than one disease process.
- A. Hemoglobin
- B. Alanine aminotransferase (ALT)
- C. Blood pressure
- D. Platelet count
Correct Answer: C,D
Rationale: Sure, here is the step-by-step rationale for why options C and D (Platelet count) are correct:
1. Blood pressure: In preeclampsia, high blood pressure is a key characteristic. Elevated blood pressure is a common finding in patients with preeclampsia, making option C consistent with preeclampsia.
2. Platelet count: HELLP syndrome is a serious complication of preeclampsia characterized by Hemolysis, Elevated Liver enzymes, and Low Platelet count. Therefore, a low platelet count is a hallmark feature of HELLP syndrome, aligning with option D.
Summary:
- Hemoglobin (Option A): Hemoglobin levels are not specific to either preeclampsia or HELLP syndrome. Therefore, this option is not selected.
- Alanine aminotransferase (ALT) (Option B): Elevated ALT levels are more specific to HELLP syndrome due to liver involvement. However, ALT
A nurse is providing preoperative teaching to a client about the administration of morphine via a PCA pump.
Which of the following statements by the client indicates an understanding of the teaching?
- A. I will receive a limited amount of pain medication when I press the button.
- B. I should have my family press the button for me when I am asleep.
- C. I can receive as much pain medication as I need by pressing the button.
- D. I should wait until my pain is severe before using the PCA pump.
Correct Answer: A
Rationale: The correct answer is A because it shows the client understands the concept of patient-controlled analgesia (PCA) pump, where they will receive a limited amount of pain medication when they press the button. This indicates the client knows they have control over their pain relief.
Choice B is incorrect as having someone else press the button goes against the purpose of PCA, which is for the patient to self-administer medication. Choice C is incorrect because unlimited medication can lead to overdose. Choice D is incorrect as waiting for severe pain can lead to ineffective pain management.
A nurse is assessing a child who has bacterial pneumonia.
Which of the following manifestations should the nurse expect?
- A. Fever
- B. Bradycardia
- C. Dry skin
- D. Decreased respiratory rate
Correct Answer: A
Rationale: The correct answer is A: Fever. When the body is fighting an infection or inflammation, fever is a common manifestation due to the release of pyrogens that reset the body's temperature. Bradycardia (B) is a slow heart rate, not typically associated with infection. Dry skin (C) is more indicative of dehydration or a skin condition. Decreased respiratory rate (D) is not a common manifestation of infection. In this case, fever is the most expected manifestation due to the body's response to an infection.