Question

A physician orders acetaminophen for a pediatric patient weighing 20 kg. The recommended dosage for acetaminophen is 10-15 mg/kg per dose, with a maximum of S doses in 24 hours. What is the maximum single safe dose (in mg) that the nurse can administer to this patient?

Answer 1

Correct Answers:

300 mg

Rationale :

✅ The recommended maximum single dose for acetaminophen in pediatrics is 15 mg/kg per dose.

✅ Calculation:

15mg×20kg=300mg (maximum per dose)

✅ The child can receive up to 5 doses in 24 hours, but the single dose must not exceed 300 mg to avoid hepatotoxicity.

✅ Always check for liver function and ensure appropriate intervals (every 4–6 hours) between doses.

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Answer 2

Correct Answers:

1000

Rationale :

✅ Rationale:

✅ The medication is given every 6 hours, which equals 4 doses in 24 hours.

✅ Calculation:

250mg per dose×4doses=1,000mg in 24 hours

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Answer 3

Correct Answers:

Activated partial thromboplastin time (aPTT)

Rationale :

🔷 Heparin therapy is monitored by aPTT because it measures the effectiveness of the intrinsic coagulation pathway, which heparin prolongs.

🔷 The therapeutic aPTT range is typically 1.5 to 2.5 times the normal value to ensure adequate anticoagulation without excessive bleeding.

🔷 INR is used to monitor warfarin, not heparin.

🔷 Platelet count is monitored for heparin-induced thrombocytopenia (HIT), but it does not assess anticoagulation effectiveness.

🔷 Hemoglobin is important for detecting bleeding but does not indicate heparin's therapeutic effect.

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Answer 4

Correct Answers:

prevent atelectasis."

Rationale :

✅ The incentive spirometer encourages deep breathing and lung expansion, which helps prevent atelectasis (collapse of alveoli) after surgery.

✅ By promoting alveolar inflation, it improves oxygenation and decreases the risk of postoperative pneumonia.

✅ It does not prevent coughing or enhance the cough reflex; in fact, coughing is encouraged postoperatively to clear secretions.

✅ "Prevent WE" is not a relevant clinical term; the primary goal is to prevent pulmonary complications.

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Answer 5

Correct Answers:

Explain the rationale for giving the medicine now

Rationale :

🔷 Preoperative antibiotics are given within a specific time frame (usually 30–60 minutes before incision) to achieve optimal tissue antibiotic levels and reduce the risk of surgical site infections.

🔷 The most therapeutic response is to educate the client about the importance and timing of the medication, promoting understanding and cooperation.

🔷 Simply insisting ("you must start now") without explanation is non-therapeutic and may increase anxiety or resistance.

🔷 Leaving and coming back later could delay administration, compromising infection prevention.

🔷 Holistic care involves addressing the client’s concerns while maintaining patient safety, which includes timely antibiotic administration.

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Answer 6

Correct Answers:

epidural or spinal block

Rationale :

✅ Epidural or spinal block anesthesia is the most commonly used method for labor because it provides effective pain relief while allowing the mother to remain awake and alert during delivery.

✅ It blocks pain transmission from the uterus and birth canal while minimizing systemic effects on the fetus.

✅ Local anesthesia is typically used only for episiotomy or perineal repair.

✅ Nerve blocks (e.g., pudendal block) may be used late in labor for perineal pain but are not the primary method for labor analgesia.

✅ General anesthesia is rarely used in labor and is reserved for emergencies (e.g., cesarean section when regional anesthesia is contraindicated).

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Answer 7

Correct Answers:

Emergency

Rationale :

🔴 Profuse bleeding from a surgical site requiring immediate return to the operating room is classified as an emergency procedure because it is life-threatening and must be done immediately to save the patient’s life or prevent serious complications.

🔴 Major surgery refers to the complexity and invasiveness but does not address urgency.

🔴 Urgent surgery is required within 24–48 hours but is not immediately life-threatening.

🔴 Elective surgery is planned in advance and not required for immediate health preservation.

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Answer 8

Correct Answers:

performing foot circles every hour while awake

Rationale :

✅ Frequent leg and foot exercises, such as foot circles, ankle pumps, and leg lifts, help promote venous return, reducing venous stasis, which is a major risk factor for deep vein thrombosis (DVT), thrombophlebitis, and pulmonary embolism (PE).

✅ Postoperative leg exercises should be done hourly while awake, not just once daily, to be effective in preventing clot formation.

✅ Alternating pressure pads are helpful for skin integrity, not specifically for DVT prevention.

✅ Massaging the calves is contraindicated because it can dislodge an existing clot, potentially causing a pulmonary embolism.

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Answer 9

Correct Answers:

Maintaining a protective environment

Rationale :

✅ Stevens-Johnson syndrome (SJS) is a severe hypersensitivity reaction characterized by widespread skin and mucous membrane blistering and sloughing, similar to burns.

✅ The priority is to maintain a protective environment to prevent secondary infections, as the extensive skin loss places the patient at high risk for sepsis.

✅ Frequent oral care is important but not the first priority compared to infection prevention.

✅ Antibiotics are only used if a confirmed secondary infection occurs; prophylactic use is not routine.

✅ Positive nitrogen balance (adequate nutrition) is important for healing but is not the immediate priority.

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Answer 10

Correct Answers:

Stage III

Rationale :

✅ A Stage III pressure ulcer is defined by full-thickness skin loss with damage or necrosis of subcutaneous tissue, which may be visible as exposed fat, but bone, tendon, or muscle are not exposed.

✅ Stage I involves intact skin with non-blanchable erythema.

✅ Stage II involves partial-thickness skin loss affecting the epidermis and/or dermis, presenting as a shallow open ulcer or blister.

✅ Stage IV involves full-thickness tissue loss with exposed bone, tendon, or muscle, often with slough or eschar.

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QLexNursing

1 :
A physician orders acetaminophen for a pediatric patient weighing 20 kg. The recommended dosage for acetaminophen is 10-15 mg/kg per dose, with a maximum of S doses in 24 hours. What is the maximum single safe dose (in mg) that the nurse can administer to this patient?

2 :
A physician orders 250 mg of a medication to be administered every 6 hours to a patient. How many milligrams of the medication will the patient receive in 24 hours?

3 :
A nurse is caring for a client who has been receiving heparin therapy. Which lab value should the nurse monitor to assess the effectiveness of the heparin therapy?

4 :
The nurse is conducting preoperative teaching with the patient and family. The nurse teaches the patient the proper use of the incentive spirometer. The nurse knows that the patient understands the need for this intervention when the patient states, "l use this device to:

5 :
A client is on the phone when the nurse brings a preoperative antibiotic before scheduled surgery. The circulating nurse has requested the antibiotic be started. The client wants the nurse to wait before starting it. What response by the nurse is most appropriate?

6 :
The nurse is caring for a client experiencing labor. Which type of anesthesia is MOST likely to be used?

7 :
The nurse is caring for a patient in the post-anesthesia care unit. The patient has developed profuse bleeding from the surgical site, and the surgeon has determined the need to return to the operative area. How will the nurse classify this procedure?

8 :
Postoperative nursing measures to prevent the development of deep vein thrombosis. thrombophlebitis, and pulmonary embolism include which of the following?

9 :
A nurse is caring for a patient diagnosed with Stevens-Johnson syndrome. Which of the following nursing interventions is the priority for this patient?

10 :
A nurse is assessing a patient's pressure ulcer and needs to determine the stage of the wound. The wound is characterized by full-thickness skin loss with exposed subcutaneous fat. but no exposed bone, tendon, or muscle. Which stage should the nurse document for this pressure ulcer?

QLexNursing

1 : A physician orders acetaminophen for a pediatric patient weighing 20 kg. The recommended dosage for acetaminophen is 10-15 mg/kg per dose, with a maximum of S doses in 24 hours. What is the maximum single safe dose (in mg) that the nurse can administer to this patient?

2 : A physician orders 250 mg of a medication to be administered every 6 hours to a patient. How many milligrams of the medication will the patient receive in 24 hours?

3 : A nurse is caring for a client who has been receiving heparin therapy. Which lab value should the nurse monitor to assess the effectiveness of the heparin therapy?

4 : The nurse is conducting preoperative teaching with the patient and family. The nurse teaches the patient the proper use of the incentive spirometer. The nurse knows that the patient understands the need for this intervention when the patient states, "l use this device to:

5 : A client is on the phone when the nurse brings a preoperative antibiotic before scheduled surgery. The circulating nurse has requested the antibiotic be started. The client wants the nurse to wait before starting it. What response by the nurse is most appropriate?

6 : The nurse is caring for a client experiencing labor. Which type of anesthesia is MOST likely to be used?

7 : The nurse is caring for a patient in the post-anesthesia care unit. The patient has developed profuse bleeding from the surgical site, and the surgeon has determined the need to return to the operative area. How will the nurse classify this procedure?

8 : Postoperative nursing measures to prevent the development of deep vein thrombosis. thrombophlebitis, and pulmonary embolism include which of the following?

9 : A nurse is caring for a patient diagnosed with Stevens-Johnson syndrome. Which of the following nursing interventions is the priority for this patient?

10 : A nurse is assessing a patient's pressure ulcer and needs to determine the stage of the wound. The wound is characterized by full-thickness skin loss with exposed subcutaneous fat. but no exposed bone, tendon, or muscle. Which stage should the nurse document for this pressure ulcer?

1 :
A physician orders acetaminophen for a pediatric patient weighing 20 kg. The recommended dosage for acetaminophen is 10-15 mg/kg per dose, with a maximum of S doses in 24 hours. What is the maximum single safe dose (in mg) that the nurse can administer to this patient?

2 :
A physician orders 250 mg of a medication to be administered every 6 hours to a patient. How many milligrams of the medication will the patient receive in 24 hours?

3 :
A nurse is caring for a client who has been receiving heparin therapy. Which lab value should the nurse monitor to assess the effectiveness of the heparin therapy?

4 :
The nurse is conducting preoperative teaching with the patient and family. The nurse teaches the patient the proper use of the incentive spirometer. The nurse knows that the patient understands the need for this intervention when the patient states, "l use this device to:

5 :
A client is on the phone when the nurse brings a preoperative antibiotic before scheduled surgery. The circulating nurse has requested the antibiotic be started. The client wants the nurse to wait before starting it. What response by the nurse is most appropriate?

6 :
The nurse is caring for a client experiencing labor. Which type of anesthesia is MOST likely to be used?

7 :
The nurse is caring for a patient in the post-anesthesia care unit. The patient has developed profuse bleeding from the surgical site, and the surgeon has determined the need to return to the operative area. How will the nurse classify this procedure?

8 :
Postoperative nursing measures to prevent the development of deep vein thrombosis. thrombophlebitis, and pulmonary embolism include which of the following?

9 :
A nurse is caring for a patient diagnosed with Stevens-Johnson syndrome. Which of the following nursing interventions is the priority for this patient?

10 :
A nurse is assessing a patient's pressure ulcer and needs to determine the stage of the wound. The wound is characterized by full-thickness skin loss with exposed subcutaneous fat. but no exposed bone, tendon, or muscle. Which stage should the nurse document for this pressure ulcer?