Nokea
Which of the following medication orders requires clarification before the nurse can administer the order?
- A. epinephrine (EpiPen) 0.25 mg IM STAT
- B. heparin 30 units/kg/hr IV infusion for 24 hours
- C. ampicillin (Omnipen) 500 mg PO bid
- D. lorazepam (Ativan) 1.0 mg PO prn
Correct Answer: B
Rationale: Heparin dosing (30 units/kg/hr) is unusually low for anticoagulation (typically 10-20 units/kg/hr). This requires clarification to ensure safety.
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The nurse is caring for a client receiving supplemental oxygen. The effectiveness of the oxygen therapy is best determined by:
- A. The rate of respirations
- B. The absence of cyanosis
- C. Arterial blood gases
- D. The level of consciousness
Correct Answer: C
Rationale: Arterial blood gases provide a direct measure of oxygenation and are the most accurate way to evaluate the effectiveness of oxygen therapy.
Prochlorperazine maleate (Compazine) 10 mg IM has been ordered for a client. The client is also to receive Stadol 2 mg IM. Before administering these medications, the nurse should
- A. obtain respirations and temperature.
- B. dilute with 9 ml of NS.
- C. draw the medications in separate syringes.
- D. verify the route of administration.
Correct Answer: C
Rationale: Compazine should be considered incompatible in a syringe with all other medications
A client with a T5 spinal cord injury suddenly begins sweating profusely in the face and neck. Vital signs reveal sudden bradycardia and significant increase in blood pressure. Which is the priority nursing action?
- A. administer nitrate or nifedipine
- B. check the client for fecal impaction
- C. check the client for bladder distention
- D. place the bed in high Fowler's position
Correct Answer: C
Rationale: These symptoms indicate autonomic dysreflexia, often triggered by bladder distention in spinal cord injuries above T6. Checking and relieving bladder distention is the priority.
After a cardiac catheterization procedure, the nurse should ask the client to remain in which position?
- A. on the left side, with both knees bent slightly
- B. semi-Fowler's position
- C. supine with a small pillow under the head
- D. high-Fowler's position
Correct Answer: C
Rationale: The supine position with a small pillow under the head promotes comfort and prevents bleeding from the catheter insertion site (usually femoral) after cardiac catheterization.
A client taking Dilantin (phenytoin) for tonic-clonic seizures is preparing for discharge. Which information should be included in the client's discharge care plan?
- A. The medication can cause dental staining.
- B. The client will need to avoid a high-carbohydrate diet.
- C. The client will need a regularly scheduled blood work.
- D. The client will need a regularly scheduled blood work.
Correct Answer: C
Rationale: Phenytoin requires regular blood work to monitor levels and prevent toxicity, which can cause side effects like gingival hyperplasia.