Nokea
The physician orders 500 mg of a medication to be given I.V. over 4 hours. The medication is diluted in 100 mL of fluid. What is the hourly flow rate in milliliters?
Correct Answer: 25 mL/hour
Rationale: Calculation: 100 mL over 4 hours = 100 ÷ 4 = 25 mL/hour. Since no options are provided, the calculated rate is noted for accuracy.
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If the following snacks are available, which one is best to meet the child's need for protein?
- A. Strawberry milkshake
- B. A popsicle stick with cinnamon
- C. Cubes of flavored gelatin
- D. Warmed beef broth
Correct Answer: D
Rationale: Warmed beef broth is a high-protein snack suitable for a burn patient, providing protein needed for tissue repair and wound healing, unlike the other options, which are lower in protein.
The parents are visiting their newborn,who is in the neonatal intensive care unit (NICU) after being diagnosed with a terminal cardiac condition. Which statement best reflects the nurse’s judgment about interventions to promote parental attachment?
- A. Interventions should be delayed until it is certain that the newborn will live.
- B. The parents should be encouraged to provide as much care as possible.
- C. The parents should only be encouraged to touch and name their newborn.
- D. The parents should be assured that they did not do anything to cause this condition.
Correct Answer: B
Rationale: Encouraging parents to provide care promotes attachment aiding coping if the infant dies. Delaying interventions limiting to touch/naming or assuming guilt are less supportive.
The nurse is concerned that a newborn may have congenital hydrocephalus. Which finding did the nurse likely observe on assessment?
- A. Bulging anterior fontanel
- B. Head and chest circumference equal
- C. A narrowed posterior fontanel
- D. Low-set ears
Correct Answer: A
Rationale: A bulging anterior fontanel suggests hydrocephalus due to increased intracranial pressure. Equal head/chest circumferences narrow posterior fontanel and low-set ears are normal or unrelated.
Which instruction is most appropriate to give to the client regarding doxycycline?
- A. The medication normally causes a dark orange discoloration of urine.
- B. Take the medication 1 hour before or 2 hours after a meal.
- C. Don't drink water for at least 30 minutes after taking the medication.
- D. Report any symptoms of GI upset to the health care provider.
Correct Answer: B
Rationale: Doxycycline should be taken on an empty stomach (1 hour before or 2 hours after a meal) to ensure optimal absorption, making this the most appropriate instruction.
Which response by the nurse would be most helpful in this situation?
- A. You should attempt to discuss the dangers of drug abuse with the patient to see if treatment is necessary.
- B. It will be necessary to get a court order before you can force your child to enter a drug treatment program.
- C. The success of the drug treatment program will depend on your child's desire to become drug-free.
- D. It's best that you force your child into the treatment program because otherwise participation probably will not occur.
Correct Answer: C
Rationale: The success of drug treatment relies on the adolescent's motivation to recover, making it important to discuss their willingness and readiness for treatment.