The physician orders palifermin (Kepivance) 60 mcg/kg to be administered daily. The client weighs 35 kg. The medication is supplied 5 mg/mL. How many mL would you administer?
- A. 0.42 mL
- B. 30 mL
- C. 36.5 mL
- D. 33.6 mL
Correct Answer: A
Rationale: Dose: 60 mcg/kg × 35 kg = 2100 mcg = 2.1 mg. 2.1 mg ÷ 5 mg/mL = 0.42 mL. Other options are incorrect calculations.
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The nurse is monitoring the contractions of a woman in labor. A contraction is recorded as beginning at 10:00 A.M and ending at 10:01 A.M. Another begins at 10:15 A.M. What is the frequency of the contractions?
- A. 14 minutes
- B. 10 minutes
- C. 15 minutes
- D. 9 minutes
Correct Answer: C
Rationale: 15 minutes. Frequency is measured from the start of one contraction to the start of the next.
During the assessment of a laboring client, the nurse notes that the FHT are loudest in the upper-left quadrant. The infant is most likely in which position?
- A. Left mentum anterior
- B. Left occipital anterior
- C. Left sacral anterior
- D. Left occipital transverse
Correct Answer: B
Rationale: Fetal heart tones loudest in the upper-left quadrant suggest a left occipital anterior position, where the fetus's back is aligned with the mother's left side. Other positions` positions are less likely.
The incidence of spinal cord defects/ neural tube defects such as meningomyelocele
The incidence of spinal cord defects/ neural tube defects such as meningomyelocele has decreased because
- A. prenatal diagnosis by ultrasound and treatment in the uterus.
- B. maternal ingestion of folic acid prior and during pregnancy.
- C. decreased incidence of smoking and alcohol use during pregnancy.
- D. genetic testing prior to pregnancy.
Correct Answer: B
Rationale: Folic acid supplementation reduces neural tube defects by supporting neural tube closure.
The nurse is caring for a client who had knee surgery this morning. Postoperative orders include a narcotic every three to four hours as needed for operative site pain and an ice bag. At 7:00 P.M., the client asks for pain medication. He was last medicated at 3:30 P.M. What is the best initial nursing action?
- A. Administer the prescribed analgesic
- B. Assess the location and nature of the pain
- C. Refill the ice bag as needed
- D. Reposition the client
Correct Answer: B
Rationale: Assessing pain location and nature ensures the medication is appropriate for operative site pain, guiding safe administration. Administering without assessment, refilling ice, or repositioning are premature.
Thrombus formation is a danger for all post operative patients. The nurse should act independently to prevent this complication by:
The nurse should act independently to prevent this complication by:
- A. Applying elastic stockings.
- B. Massaging gently with lotion.
- C. Encouraging in-bed exercises.
- D. Providing adequate fluids intake.
Correct Answer: C
Rationale: In-bed exercises promote venous return, reducing the risk of thrombus formation.
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