Nokea
Which is the correct volume needed for the nurse to administer the prescribed dose of 0.1 mg of epinephrine to the client?
- A. 0.001 mL
- B. 0.1 mL
- C. 1.0 mL
- D. 10 mL
Correct Answer: B
Rationale: For a 1:1,000 epinephrine solution (1 mg/mL), a 0.1 mg dose equals 0.1 mL, calculated as 0.1 mg ÷ 1 mg/mL = 0.1 mL.
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The nurse is preparing to administer influenza vaccines to a group of elderly clients in a long-term care facility. Which client should the nurse question receiving the vaccine?
- A. The client diagnosed with congestive heart failure.
- B. The client with a documented allergy to eggs.
- C. The client who has had an anaphylactic reaction to penicillin.
- D. The client who has an elevated blood pressure and pulse.
Correct Answer: B
Rationale: Influenza vaccines are often grown in eggs, making egg allergy (B) a contraindication due to anaphylaxis risk. Congestive heart failure (A), penicillin allergy (C), and elevated vitals (D) are not contraindications for the flu vaccine.
The nurse performs postural drainage on the client. Which nursing intervention is most beneficial to loosen secretions?
- A. Telling the client to take deep breaths
- B. Striking the back with a cupped hand
- C. Applying pressure below the diaphragm
- D. Placing the client in a sitting position
Correct Answer: B
Rationale: Striking the back with a cupped hand (percussion) helps loosen secretions during postural drainage.
The nurse is caring for the client diagnosed with pneumonia. Which information should the nurse include in the teaching plan? Select all that apply.
- A. Place the client on oxygen delivered by nasal cannula.
- B. Plan for periods of rest during activities of daily living.
- C. Place the client on a fluid restriction of 1,000 mL/day.
- D. Restrict the client's smoking to two (2) to three (3) cigarettes per day.
- E. Monitor the client's pulse oximetry readings every four (4) hours.
Correct Answer: B,E
Rationale: Rest periods (B) conserve energy, and pulse oximetry (E) monitors oxygenation in pneumonia. Oxygen (A) depends on SpO2, fluid restriction (C) is inappropriate, and smoking (D) must stop.
An alarm beeps notifying you that one of your patient's oxygen saturation is reading $89 \%$. You arrive to the patient's room, and see the patient comfortably resting in bed watching television. The patient is already on $2 \mathrm{~L}$ of oxygen via nasal cannula. The patient is admitted for COPD exacerbation. Your next nursing action would be:
- A. Continue to monitor the patient
- B. Increase the patient's oxygen level to $3 \mathrm{~L}$
- C. Notify the doctor for further orders
- D. Turn off the alarm settings
Correct Answer: A
Rationale: In COPD, oxygen saturation of 88-92% is acceptable to avoid suppressing the hypoxic drive. Since the patient is comfortable, continue monitoring . Increasing oxygen or notifying the doctor is unnecessary unless symptoms worsen.
Which assessment data indicate to the nurse the chest tubes inserted three (3) days ago have been effective in treating the client with a hemothorax?
- A. Gentle bubbling in the suction compartment.
- B. No fluctuation (tidaling) in the water-seal compartment.
- C. The drainage compartment has 250 mL of blood.
- D. The client is able to deep breathe without any pain.
Correct Answer: B
Rationale: No tidaling (B) indicates lung re-expansion, showing effective hemothorax treatment. Bubbling (A) suggests air leak, drainage (C) is expected, and pain-free breathing (D) is secondary.