Question

A nurse is preparing to administer diphenhydramine 30 mg 1M stat to a client who is having an allergic reaction. Available is diphenhydramine 50 mg/l mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Answer 1

Correct Answers:

0.6

Rationale :

🔷 Use dose–volume formula: Volume = Ordered dose ÷ Stock concentration = 30 mg ÷ 50 mg/mL.

🔷 Calculation yields 0.6 mL, which matches IM dose accuracy to the nearest tenth.

🔷 No trailing zero and use a leading zero when needed are medication-safety standards.

🔷 Drawing 0.6 mL prevents underdose (e.g., 0.5 mL) or overdose (≥0.7 mL).

🔷 Verify drug, dose, route (IM), time (stat) against MAR before administration.

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Answer 2

Correct Answers:

Obtain an EKG.

Rationale :

🟩 Jaw/back/shoulder pain with SOB and nausea are classic acute coronary syndrome red flags.

🟩 A 12-lead ECG is the first diagnostic step to detect ischemia/ST-elevation.

🟩 Early ECG guides reperfusion timelines and antiplatelet/anticoagulant decisions.

🟩 Analgesics/NSAIDs can mask symptoms and aren’t diagnostic; ECG is time-critical.

🟩 Maintain O₂ ≥ 92% as supportive care, but ECG establishes the diagnosis pathway.

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Answer 3

Correct Answers:

Previous intubation due to status asthmatic us episode

Rationale :

🔶 Prior intubation for asthma is a strong predictor of future life-threatening exacerbations.

🔶 It signals severe airway hyper-responsiveness and risk of rapid decompensation.

🔶 History supersedes general triggers (irritants, infections) in risk stratification.

🔶 These clients require aggressive action plans and early escalation thresholds.

🔶 Education on controller adherence and prompt ED evaluation is essential.

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Answer 4

Correct Answers:

Tachycardia

Rationale :

💠 Low TSH with high T4/T3 indicates hyperthyroidism (increased metabolic rate).

💠 Elevated thyroid hormone increases β-adrenergic activity, producing tachycardia.

💠 Clients report heat intolerance, weight loss, anxiety, consistent with thyrotoxicosis.

💠 Vital signs commonly show ↑ HR, possible ↑ SBP, and warm, moist skin.

💠 Monitoring HR and arrhythmias (e.g., AF) is clinically important

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Answer 5

Correct Answers:

Irregular

Rationale :

🔷 Atrial fibrillation causes an irregularly irregular pulse—no repeating pattern.

🔷 Erratic atrial depolarization leads to variable ventricular response.

🔷 Apical–radial pulse deficit may be present due to variable stroke volumes.

🔷 Expect uneven pulse amplitude and inconsistent intervals on palpation.

🔷 Correlate with ECG findings: absent P waves, irregular R–R intervals.

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Answer 6

Correct Answers:

"Place the tablet under your tongue, and then take a small sip of water."

Rationale :

🟩 Sublingual nitroglycerin needs moist mucosa for rapid absorption (1–3 min).

🟩 A small sip of water helps dissolve the tablet if the mouth is dry, enhancing uptake.

🟩 Educate to sit/lie down due to vasodilation and risk of hypotension/dizziness.

🟩 Headache/flushing are expected; do not stop the medication for these effects.

🟩 May be used prophylactically before exertion that provokes angina.

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Answer 7

Correct Answers:

"l should buy new shoes late in the day."

Rationale :

🔶 Feet are largest late in the day; fitting then reduces pressure points/blisters.

🔶 Diabetes causes neuropathy; proper fit prevents ulcers and skin breakdown.

🔶 Choose wide, protective footwear; avoid open-toe or tight shoes.

🔶 Wear clean, cotton socks (avoid nylon) to reduce moisture/friction.

🔶 Inspect feet daily and report redness, calluses, lesions early.

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Answer 8

Correct Answers:

4

Rationale :

💠 Ordered 40 mg, stock 10 mg/mL → Volume = 40 ÷ 10 = 4 mL.

💠 Nearest whole number is appropriate here (exactly 4 mL).

💠 Confirm IV push rate per furosemide guidelines to avoid ototoxicity.

💠 Assess BP, urine output, and electrolytes (especially K⁺) pre/post dose.

💠 Use a needle-free port and flush per IV standards.

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Answer 9

Correct Answers:

0745

Rationale :

🔷 Regular insulin onset 30–60 min; breakfast at ~30 min prevents hypoglycemia.

🔷 Giving food too early/late mismatches insulin action and glucose availability.

🔷 Peak 2–4 h; schedule mid-morning snack PRN to prevent late hypo.

🔷 Coordinate dose–meal timing consistently to stabilize glycemic control.

🔷 Monitor pre-meal glucose and reassess symptoms post-dose.

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Answer 10

Correct Answers:

Spontaneous bleeding

Rationale :

🟩 Platelets 9,000/mm³ = severe thrombocytopenia (critical bleeding risk).

🟩 Expect petechiae, ecchymoses, mucosal bleed, and potential intracranial hemorrhage.

🟩 Avoid IM injections, rectal temps, and antiplatelet/anticoagulant drugs.

🟩 Implement bleeding precautions: soft toothbrush, electric razor, gentle oral care.

🟩 Prepare for platelet transfusion and monitor Hgb/Hct and neuro status.

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QLexNursing

2 :
A nurse on a medical-surgical unit is caring for a client who reports pain in the jaw, back, and shoulder, and shortness of breath and nausea. Which of the following actions should the nurse take?

3 :
Which of the following risk factors is associated with a client having a higher risk of experiencing status asthmatics?

5 :
A nurse is assessing a client who has atrial fibrillation. Which of the following pulse characteristics should the nurse expect?

6 :
A nurse is providing instructions to a client who has a new prescription for sublingual nitroglycerin (Nitrostat) to treat angina pectoris. Which of the following instructions should the nurse include?

7 :
A nurse is providing teaching about foot care for a client who has type 2 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?

8 :
A nurse is preparing to administer furosemide 40 mg via IV bolus to a client. The amount available is furosemide 10 mg/l mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

9 :
A nurse is caring for a client with diabetes mellitus who is prescribed regular insulin via a sliding scale. After administering the correct dose at 0715. the nurse should ensure the client receives breakfast at which of the following times?

10 :
A nurse is reviewing a client's CBC findings and discovers that the clients platelet count is 9.000/mm3. The nurse should monitor the client for which of the following conditions?

QLexNursing

2 : A nurse on a medical-surgical unit is caring for a client who reports pain in the jaw, back, and shoulder, and shortness of breath and nausea. Which of the following actions should the nurse take?

3 : Which of the following risk factors is associated with a client having a higher risk of experiencing status asthmatics?

5 : A nurse is assessing a client who has atrial fibrillation. Which of the following pulse characteristics should the nurse expect?

6 : A nurse is providing instructions to a client who has a new prescription for sublingual nitroglycerin (Nitrostat) to treat angina pectoris. Which of the following instructions should the nurse include?

7 : A nurse is providing teaching about foot care for a client who has type 2 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?

8 : A nurse is preparing to administer furosemide 40 mg via IV bolus to a client. The amount available is furosemide 10 mg/l mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

9 : A nurse is caring for a client with diabetes mellitus who is prescribed regular insulin via a sliding scale. After administering the correct dose at 0715. the nurse should ensure the client receives breakfast at which of the following times?

10 : A nurse is reviewing a client's CBC findings and discovers that the clients platelet count is 9.000/mm3. The nurse should monitor the client for which of the following conditions?

2 :
A nurse on a medical-surgical unit is caring for a client who reports pain in the jaw, back, and shoulder, and shortness of breath and nausea. Which of the following actions should the nurse take?

3 :
Which of the following risk factors is associated with a client having a higher risk of experiencing status asthmatics?

5 :
A nurse is assessing a client who has atrial fibrillation. Which of the following pulse characteristics should the nurse expect?

6 :
A nurse is providing instructions to a client who has a new prescription for sublingual nitroglycerin (Nitrostat) to treat angina pectoris. Which of the following instructions should the nurse include?

7 :
A nurse is providing teaching about foot care for a client who has type 2 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?

8 :
A nurse is preparing to administer furosemide 40 mg via IV bolus to a client. The amount available is furosemide 10 mg/l mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

9 :
A nurse is caring for a client with diabetes mellitus who is prescribed regular insulin via a sliding scale. After administering the correct dose at 0715. the nurse should ensure the client receives breakfast at which of the following times?

10 :
A nurse is reviewing a client's CBC findings and discovers that the clients platelet count is 9.000/mm3. The nurse should monitor the client for which of the following conditions?