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The staff nurse in a regional hospital is aware that a dose of parenteral ampicillin must be administered within how many hours after it has been mixed?
- A. 1 hour
- B. 4 hours
- C. 2 hours
- D. 8 hours
Correct Answer: B
Rationale: The correct administration time frame for a dose of parenteral ampicillin after it has been mixed is within 4 hours. This is based on the stability and compatibility of ampicillin when it is mixed and prepared for injection. Beyond 4 hours, the effectiveness and safety of the medication may be compromised due to potential degradation or contamination. It is crucial for healthcare providers to adhere to the recommended administration time frame to ensure the patient receives the full therapeutic benefits of the medication and to prevent any negative outcomes associated with the degradation of the drug.
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Mrs. Go a 75-year old female suffered a fdall and is diagnosed with a herniated nucleus pulposus at the C4-C5 interspace, and a second st the C5-C6 interspace.Which of the following findings would the nurse expect to discover during the assessment?
- A. constant, throbbing headaches
- B. clonus in the lower extremities
- C. Numbness of the face
- D. pain in the scapular region
Correct Answer: D
Rationale: A herniated nucleus pulposus at the C4-C5 and C5-C6 interspace typically results in neck and shoulder pain, which can radiate to the scapular region. The herniation at these levels can cause irritation or compression of the cervical nerve roots leading to pain, numbness, tingling, or weakness in the affected areas. Constant, throbbing headaches are not typically associated with this specific diagnosis. Clonus in the lower extremities and numbness of the face are also not common findings related to herniated nucleus pulposus at the cervical spine levels mentioned.
A 7 year old boy came to OPD with history of difficulty in rising up from sitting position. Examination reveals hypertrophy of calf muscles with trendelenburg gait. The most likely diagnosis is:
- A. Becker's muscular dystrophy
- B. Duchenne muscular dystrophy
- C. Myotonic muscular dystrophy
- D. Cerebral palsy
Correct Answer: B
Rationale: Duchenne muscular dystrophy typically presents in early childhood with difficulty rising from a seated position (Gower's sign), calf muscle hypertrophy, and Trendelenburg gait.
Nurse Lorna is assessing infantile reflexes in a 9-month-old baby; which of the following would she identify as normal?
- A. Persistent rooting
- B. Bilateral parachute
- C. Absent moro reflex
- D. Unilateral grasp
Correct Answer: B
Rationale: The parachute reflex typically emerges around 9 months of age and is considered a normal reflex in infants. This reflex is characterized by the infant extending their arms to protect themselves when they feel like they are falling. This is an important protective reflex that helps a child develop their sense of balance and coordination. Persistent rooting is not a normal reflex in a 9-month-old baby, as it typically disappears by 4 months of age. The Moro reflex is typically present in infants and involves an outstretched movement of the arms when startled, so its absence would not be considered normal at this age. A unilateral grasp is also not a normal reflex at 9 months, as infants should be able to show coordinated bilateral movements by this age.
The nurse is caring for a client with bronchogenic carcinoma. Which nursing diagnosis takes highest priority?
- A. Disturbed body image related to changes in body functions
- B. Ineffective airway clearance related to obstruction by a tumor or secretions
- C. Anxiety related to actual threat to health status and changes in family dynamics
- D. Imbalanced nutrition: Less than body requirements related to anorexia and vomiting secondary to chemotherapy
Correct Answer: B
Rationale: In caring for a client with bronchogenic carcinoma, the highest priority nursing diagnosis would be Ineffective airway clearance related to obstruction by a tumor or secretions. This is crucial because any blockage in the airway can lead to serious respiratory complications, such as respiratory distress or respiratory failure. Ensuring effective airway clearance is essential to maintain adequate oxygenation and ventilation for the client. Addressing this priority nursing diagnosis promptly can help prevent potential life-threatening situations and promote optimal respiratory function for the client.
The nurse is caring for a client with diabetes insipidus. The nurse should anticipate the administration of:
- A. insulin.
- B. poatassium chloride.
- C. furosemide (Lasix)
- D. vasopressin (Pitressin).
Correct Answer: D
Rationale: Diabetes insipidus is a condition characterized by the inability of the kidneys to conserve water, leading to excessive urination and extreme thirst. The main treatment for diabetes insipidus is the administration of vasopressin (also known as antidiuretic hormone or ADH). Vasopressin helps the kidneys retain water, reduce urine output, and stabilize the body's fluid balance. Therefore, in caring for a client with diabetes insipidus, the nurse should anticipate the administration of vasopressin to help manage the symptoms of excessive urination and dehydration.