Nokea
The physician has ordered that ampicillin 250 mg IV be given over 30 minutes. The medication is diluted as recommended in 10 mL in the volume control chamber of a set that has a tubing of 12 mL. Which nursing measure is most accurate considering these facts?
- A. Infuse volume at 44 mL/hr.
- B. Infuse volume at 22 mL/hr.
- C. Infuse volume at 10 mL/hr.
- D. Infuse volume at 30 mL/hr.
Correct Answer: A
Rationale: The volume to be infused should be diluted medication volume added to the volume control chamber (10 mL) plus the tubing volume (12 mL). The general formula for calculating IV medications for children is: Rate = Volume to Be Infused X Administration Set Drop Factor (microdrop: 60 gtts/min) / Desired Time to Infuse in Minutes Rate = (10 + 12) 22 × 60 / 30 = 44 mL/hr. (B, C, D) These values are incorrect.
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A client with a history of ovarian cancer is admitted with complaints of abdominal swelling. The nurse should give priority to:
- A. Monitoring for ascites
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering chemotherapy
Correct Answer: A
Rationale: Abdominal swelling in ovarian cancer often indicates ascites, so monitoring for ascites is the priority to guide treatment.
A client with a history of renal failure is admitted with complaints of shortness of breath. The nurse should expect the client to have:
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: A
Rationale: Renal failure impairs acid excretion, leading to metabolic acidosis, which can cause compensatory hyperventilation and shortness of breath.
The client is admitted with a diagnosis of vasa previa. Which delivery method is most likely to be planned?
- A. Vaginal delivery
- B. Cesarean section
- C. Forceps-assisted delivery
- D. Vacuum-assisted delivery
Correct Answer: B
Rationale: Vasa previa with fetal vessels crossing the cervical os requires cesarean section to prevent vessel rupture and fetal exsanguination during vaginal delivery. Forceps or vacuum delivery increases risk.
Arterial ulcers are best described as ulcers that:
- A. Are smooth in texture
- B. Have irregular borders
- C. Are cool to touch
- D. Are painful to touch
Correct Answer: D
Rationale: Arterial ulcers caused by poor blood flow are typically painful due to tissue ischemia. They often have irregular borders a pale base and may be cool due to reduced circulation but pain is the most defining feature.
A female client was recently diagnosed with gastric cancer. She entered the hospital and had a total gastrectomy with esophagojejunostomy. Her postoperative recovery was uneventful. On conducting discharge teaching, the nurse discusses changes in bodily function and lifestyle changes with the client. In order to prevent pernicious anemia, the nurse stresses that the client must:
- A. Receive monthly blood transfusions
- B. Increase the amount of iron in her diet
- C. Eat small quantities several times daily until she is able to tolerate food in moderate portions
- D. Understand the need for Vitamin B12 replacement therapy
Correct Answer: D
Rationale: Monthly blood transfusions are not indicated postgastrectomy. Increasing iron in the client's diet may cause irritation and will not alleviate pernicious anemia. It may be necessary that the client eat small meals several times per day, but this measure has no relevance to prevention of pernicious anemia. Pernicious anemia is caused by lack of Vitamin B12, and replacement therapy will be necessary because the client's stomach has been removed.