Nokea
The physician orders a Lidocaine drip to infuse at 2 mg/min. The drug is available as 2 gm in 500 mL of fluid. Solve for mL/hr.
Correct Answer: 3
Rationale: To solve for mL/hr, we first need to convert 2 gm to mg (2000 mg) and calculate the total volume in mL (500 mL). Then, we divide the total volume by the rate of infusion (2 mg/min) to get mL/min (250 mL/min). Finally, multiply this by 60 to get mL/hr (15000 mL/hr). Choice 3 is correct because it correctly follows these steps. Other choices are incorrect due to miscalculations or skipping a step.
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A nurse is assessing a client diagnosed with schizophrenia who has been treated with fluphenazine (Prolixin) for several years. Which of the following findings should the nurse document as manifestations of tardive dyskinesia (TD)?
- A. Sudden onset of high fever
- B. Twisting tongue movements
- C. Constant tapping of feet when sitting
- D. Shuffling gait
Correct Answer: B
Rationale: Twisting tongue movements are a classic sign of tardive dyskinesia from long-term antipsychotic use.
Charles, the nurse, is working in an emergency department and is assessing a preschool-age child who reports abdominal pain. Which of the following findings should alert the nurse to possible abuse (select all that apply)
- A. Areas of ecchymosis on the torso.
- B. Mismatched clothing
- C. Abrasions on knees
- D. Abdominal rebound tenderness
- E. Round burn marks on forearms
Correct Answer: A,E
Rationale: The correct answers are A and E. Ecchymosis on the torso may indicate physical abuse, and burn marks on the forearms suggest possible abuse as well. Mismatched clothing (B) is not a direct indicator of abuse but may suggest neglect. Abrasions on knees (C) are common in preschool-age children and do not specifically point to abuse. Abdominal rebound tenderness (D) is a medical finding that may indicate a health issue but does not directly correlate with abuse. Overall, A and E are the most concerning findings that should alert the nurse to possible abuse.
A nurse is providing teaching to a client diagnosed with schizophrenia and is prescribed haloperidol (Haldol). Which of the following information should the nurse include in the teaching?
- A. This medication will decrease your symptoms of OCD.
- B. This medication may cause excessive salivation.
- C. You can stop taking the medication if the side effects are bothersome.
- D. You may experience dizziness upon standing while taking this medication.
Correct Answer: D
Rationale: The correct answer is D: You may experience dizziness upon standing while taking this medication. This is important information to include because haloperidol can cause orthostatic hypotension, leading to dizziness upon standing. This is a common side effect that the client should be aware of to prevent falls. Option A is incorrect because haloperidol is not used to treat OCD. Option B is incorrect because excessive salivation is not a common side effect of haloperidol. Option C is incorrect because it is crucial not to stop taking antipsychotic medications abruptly without consulting a healthcare provider.
A nurse in a substance abuse clinic is assessing a client who is prescribed disulfiram (Antabuse). The client states he stopped the medication after developing severe nausea and vomiting. Which of the following does the nurse realize is most likely the cause of the client's symptoms?
- A. The client took an overdose of the medication.
- B. The client demonstrated an allergic response to the medication.
- C. The client experienced a common side effect of the medication.
- D. The client consumed alcohol while taking the medication.
Correct Answer: D
Rationale: The correct answer is D: The client consumed alcohol while taking the medication. Disulfiram is used to deter alcohol consumption by causing unpleasant reactions when alcohol is ingested. The symptoms of severe nausea and vomiting the client experienced are consistent with the disulfiram-alcohol reaction. This reaction occurs when alcohol is consumed while on disulfiram, leading to a buildup of acetaldehyde, causing discomfort.
Choice A: The client taking an overdose of the medication would typically result in different symptoms, such as neurological effects or liver toxicity.
Choice B: An allergic response to disulfiram would likely manifest as skin rash, itching, or difficulty breathing, rather than nausea and vomiting.
Choice C: While nausea and vomiting are common side effects of disulfiram, they are typically milder and occur when alcohol is consumed, not as a standalone symptom.
A nurse is assessing a client who is experiencing a thyroid storm. Which of the following findings should the nurse anticipate?
- A. Coma
- B. Hypothermia
- C. Tachycardia
- D. Fruity smelling breath
Correct Answer: C
Rationale: The correct answer is C: Tachycardia. In a thyroid storm, there is an excessive release of thyroid hormones leading to severe symptoms. Tachycardia is a hallmark sign due to the increased metabolic rate and sympathetic response. Coma (A) is a severe complication but not an anticipated finding. Hypothermia (B) is incorrect as the body temperature is typically elevated. Fruity smelling breath (D) is more indicative of diabetic ketoacidosis, not thyroid storm.