Nokea
The physician has ordered Claforan (cefotaxime) 1 g every 6 hours. The pharmacy sends the medication premixed in 100 mL of D5W with instructions to infuse the medication over 1 hour. The IV set delivers 20 drops per milliliter. The nurse should set the IV rate at:
- A. 50 drops per minute
- B. 33 drops per minute
- C. 25 drops per minute
- D. 12 drops per nursing diagnosis.
- E. 33 drops per minute
- F. The IV rate is calculated as: 100 mL over 60 minutes with 20 drops/mL = (100 × 20) ÷ 60 = 33.33 drops/min, rounded to 33 drops/min.
Correct Answer:
Rationale:
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A homeless client has been admitted to the hospital for observation, and he does not speak any English. The nurse does not know any of the client's medical history, but he is grimacing and looks to be in pain. The nurse should
- A. use nonverbal communication such as pointing and gestures.
- B. call for the hospital interpreter services.
- C. give the client pen and paper and encourage him to draw.
- D. wait to see if any friends or family visit the client who may be able to help.
Correct Answer: B
Rationale: An interpreter ensures accurate communication for assessing pain and history, respecting patient needs and safety.
A client with cocaine addiction would most likely be placed on which medication?
- A. Amantadine (Symmetrel)
- B. Methadone
- C. THC
- D. Disulfiram (Antabuse)
Correct Answer: A
Rationale: Amantadine is sometimes used to reduce cravings in cocaine addiction by modulating dopamine pathways, unlike the other options, which are used for different substance dependencies.
The clinic nurse is seeing a client who suffers from caregiver strain due to caring for her elderly parents who have dementia and live with her. Which action by the nurse during the assessment is most important?
- A. ask the client about her support systems
- B. ask the client what she does for relaxation
- C. ask if her parents' insurance covers adult day care for them
- D. offer to give her a list of nursing homes to care for her parents
Correct Answer: A
Rationale: Assessing support systems identifies resources to alleviate caregiver strain, guiding interventions to reduce stress.
A client has had diarrhea for the past 3 days. Which acid/base imbalance would the nurse expect the client to have?
- A. Respiratory alkalosis
- B. Metabolic acidosis
- C. Metabolic alkalosis
- D. Respiratory acidosis
Correct Answer: B
Rationale: Prolonged diarrhea leads to loss of bicarbonate, causing metabolic acidosis.
A 49-year-old female suffered a stroke that resulted in dysphagia. The dietician orders a diet of dysphagia-pureed foods. Which of the following foods would be an appropriate choice?
- A. beef stew
- B. hard-boiled egg
- C. custard
- D. sliced peaches
Correct Answer: C
Rationale: Custard is smooth and pureed, suitable for a dysphagia diet. Other options pose choking risks due to texture.