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Which statement by the parent of a child with sickle cell anemia indicates an understanding of the disease.
- A. The pain he has is due to the presence of too many red blood cells.'
- B. He will be able to go snow skiing with his friends as long as he stays warm.'
- C. He will need extra fluids in the summer to prevent dehydration.'
- D. There is very little chance that his brother will have sickle cell.'
Correct Answer: C
Rationale: Extra fluids in summer prevent dehydration, which can trigger sickle cell crises. Pain is due to vaso-occlusion, not excess RBCs; skiing risks hypoxia; siblings have a 25% chance of inheriting the disease.
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A nurse from the float pool is giving medications on a pediatric unit and is to give medications to a 2-year-old child in room 534, bed B. The child in that room does not have an identification band. What is the best action for the nurse to take?
- A. Ask the child what his name is
- B. Give the medication to the child in room 534, bed B
- C. Refuse to give the medication
- D. Ask the adults beside the bed the name of the child in that bed
Correct Answer: C
Rationale: Refusing to give medication without proper identification ensures safety, as a 2-year-old cannot reliably confirm identity.
The most common complication following a myocardial infarction is:
- A. Hyperkalemia
- B. Cardiac dysrhythmia
- C. Acute respiratory distress
- D. Hypovolemic shock
Correct Answer: B
Rationale: Cardiac dysrhythmias are the most common complication post-myocardial infarction due to ischemic changes affecting the heart's electrical conduction.
The nurse is caring for a client who has a prescription for albuterol 5 mg via nebulizer every 4 hours. The nurse has albuterol 2.5 mg/3 mL available. How many mL should the nurse administer to the client with each dose? Record your answer using a whole number.
Correct Answer: 6 mL/dose
Rationale: Albuterol 5 mg is needed, with 2.5 mg/3 mL available. Thus, 5 mg ÷ 2.5 mg × 3 mL = 6 mL per dose.
The nurse is caring for a client who has a prescription for clarithromycin 7.5 mg/kg/day PO in 2 divided doses. The client weighs 78 lb. How many mL should the nurse administer for each dose? Record your answer using 1 decimal place.
Correct Answer: 7.5 mL/dose
Rationale: Client weight: 78 lb ÷ 2.2 = 35.45 kg. Dose: 7.5 mg/kg/day × 35.45 kg = 265.875 mg/day ÷ 2 doses = 132.9375 mg/dose. Clarithromycin is typically 250 mg/5 mL. Thus, 132.9375 mg × (5 mL/250 mg) = 2.65875 mL ≈ 2.7 mL/dose.
The nurse is collecting data from a client who had a transurethral resection of the prostate 10 hours ago and is receiving continuous bladder irrigation. Which of the following findings would require follow-up?
- A. blood pressure of 114/70 mm Hg and heart rate of 66/min
- B. reports relief of bladder spasms after administration of oxybutynin
- C. light pink urine is noted in the catheter tubing and urinary drainage bag
- D. bladder irrigation input of 3000 mL and urine output of 2800 mL over the past 4 hours
Correct Answer: D
Rationale: A 200 mL discrepancy between irrigation input and output suggests possible catheter obstruction or absorption, requiring follow-up. Normal vitals , spasm relief , and light pink urine are expected post-TURP.