Question

A client is prescribed epoetin alfa 8.00units subcutaneous three times per week. The medication is available in 20,000 units/mL. Determine how many mL the nurse will administer per dose. (Round to the nearest tenth)

Answer 1

Correct Answers:

0.4

Rationale :

1️⃣ Identify the prescribed dose:

8,000 units

2️⃣ Identify the available concentration:

20,000 units/mL

3️⃣ Use the formula:

mL to give = Prescribed dose ÷ Available concentration

4️⃣ Substitute the values:

mL to give = 8,000 ÷ 20,000

5️⃣ Solve:

mL to give = 0.4 mL

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Answer 2

Correct Answers:

"I will alert the nurse if i have any decrease in hearing."

Rationale :

🔵 After a tympanoplasty, a temporary decrease in hearing is expected due to packing in the ear canal and postoperative swelling.

🔵 The client does not need to report this immediately unless hearing loss persists after packing removal or is accompanied by severe pain or drainage, which could indicate complications.

🔵 The other statements reflect appropriate postoperative care, such as lying on the back or unoperated side to prevent pressure, coughing/sneezing with the mouth open to reduce middle ear pressure, and calling for assistance to prevent dizziness-related falls.

🔵 Education should emphasize that temporary hearing changes are normal during healing.

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Answer 3

Correct Answers:

Respiratory rate 8 breaths/minute

Rationale :

🟥 A respiratory rate of 8 breaths/minute indicates respiratory depression, which is a medical emergency in a client with COPD.

🟥 High-flow oxygen (5 L/min) can suppress the client’s hypoxic respiratory drive, leading to CO2 retention and possible respiratory failure.

🟥 The other findings—barrel chest, expiratory wheezes, and tripod positioning—are typical chronic manifestations of COPD and not immediately life-threatening.

🟥 The nurse should reduce oxygen to the lowest effective flow, monitor ABGs, and prepare for possible ventilatory support.

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Answer 4

Correct Answers:

Administer half the ordered dose of phenytoin and document the phenytoin level

Rationale :

🟢 The therapeutic serum level of phenytoin is 10–20 mcg/mL. A level of 12 mcg/mL is within the normal therapeutic range, indicating effective seizure control without risk of toxicity.

🟢 There is no need to hold or adjust the dose when levels are within this range.

🟢 Toxic effects (e.g., nystagmus, ataxia, confusion) typically occur when levels exceed 20 mcg/mL.

🟢 The nurse should continue to administer the medication as prescribed and monitor for any neurological changes or signs of toxicity.

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Answer 5

Correct Answers:

Instruction on how to instill artificial tears ophthalmic drops.

Rationale :

🔵 Grave’s disease is characterized by hyperthyroidism, where elevated T3 & T4 levels cause increased metabolism and exophthalmos (protruding eyes).

🔵 Artificial tears help prevent corneal dryness, irritation, and injury due to reduced eyelid closure associated with exophthalmos.

🔵 A cool environment (not warm) is preferred because of heat intolerance caused by increased metabolic rate.

🔵 A high-calorie, high-protein diet is recommended due to hypermetabolism, not a low-calorie diet.

🔵 Semi-private rooms are not a priority; rest and stress reduction are more important.

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Answer 6

Correct Answers:

Assess the client for bruising and tarry stool

Rationale :

🟠 Thrombocytopenia is characterized by a low platelet count, increasing the risk for spontaneous bleeding.

🟠 Bruising (ecchymosis), petechiae, and tarry stools (melena) are signs of bleeding and gastrointestinal hemorrhage, which can be life-threatening if undetected.

🟠 Frequent assessment allows for early intervention, such as platelet transfusion or other bleeding precautions.

🟠 Other options (e.g., temperature monitoring, bed rest) are supportive but bleeding assessment is the priority due to the immediate risk of hemorrhage.

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Answer 7

Correct Answers:

51 -year-old with asthma who reports shortness of breath after using a bronchodilator inhaler.

Rationale :

🟥 Asthma with shortness of breath after bronchodilator use indicates a possible status asthmaticus or worsening bronchospasm, which is a respiratory emergency.

🟥 The priority is to assess airway and breathing (ABCs) immediately to prevent respiratory failure.

🟥 The other clients are stable in comparison: a COPD patient with 92% O2 saturation is expected, sputum collection is not urgent, and IV antibiotics can be delayed briefly.

🟥 Immediate assessment and intervention for the asthmatic client can be life-saving.

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Answer 8

Correct Answers:

"I want to understand how you feel about your appearance. Please tell me more."

Rationale :

🟣 Cushing’s syndrome causes physical changes such as moon face, truncal obesity, and striae, which can lead to body image disturbances and low self-esteem.

🟣 This response uses therapeutic communication, encouraging the client to express feelings and discuss concerns openly.

🟣 Validating and exploring the client’s emotions is essential to provide emotional support and develop coping strategies.

🟣 The other responses either dismiss the client’s feelings or attempt to change the subject, which is non-therapeutic.

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Answer 9

Correct Answers:

Be sure not to cross your legs."

Rationale :

🔵 After a posterior/lateral total hip replacement, patients must follow hip precautions to prevent hip dislocation.

🔵 Crossing legs causes adduction and internal rotation, which increases the risk of dislocating the prosthetic hip joint.

🔵 Other important precautions include using an abduction pillow, avoiding hip flexion beyond 90 degrees, and using an elevated toilet seat.

🔵 Pain medication is often necessary postoperatively, and early ambulation with assistance is encouraged, not prolonged bed rest.

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Answer 10

Correct Answers:

report of particles floating in the visual field

Rationale :

🟢 A detached retina typically presents with early warning signs such as floaters (particles or cobwebs in the visual field) and flashes of light (photopsia) before progressing to sudden, painless vision loss.

🟢 These symptoms occur due to traction on the retina as it begins to separate from the underlying choroid.

🟢 Central blind spots are more characteristic of macular degeneration, and increased tearing or severe headaches are not typical features of retinal detachment.

🟢 Prompt recognition and immediate ophthalmologic intervention are critical to prevent permanent vision loss.

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Custom- Spring 2025 Final Exam (Revised SATAS)

No.

1 :
A client is prescribed epoetin alfa 8.00units subcutaneous three times per week. The medication is available in 20,000 units/mL. Determine how many mL the nurse will administer per dose. (Round to the nearest tenth)

2 :
The nurse is providing post operative education for a client scheduled for a tympanoplasty. Which statement made by the client indicates that additional education is needed?

3 :
The nurse is assessing a client with chronic obstructive pulmonary disease (COPD). The client is receiving oxygen at a flow rate of 5 liters per minute via nasal cannula. Which finding is most concerning?

4 :
The nurse is preparing to administer medications and finds that the clients serum phenytoin level is 12 mcg/mL. What is the appropriate action by the nurse

5 :
Nursing care of a patient with Grave's disease whose T3 & T4 are elevated would most likely include which activity?

6 :
A client is admitted to the hospital for evaluation and treatment of thrombocytopenia. Which action is most important for the nurse to implement?

7 :
Which client should the nurse assess first after receiving change of shift report?

8 :
During an assessment, a Cushings patient tells the nurse she just looks awful and does not want anyone to be around her. Which would be the nurse best response?

9 :
Which is appropriate to teach a patient following a posterior/lateral total hip replacement?

10 :
In addition to sudden vision loss, the nurse would expect which clinical manifestation in a client with a detached retina?

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Custom- Spring 2025 Final Exam (Revised SATAS)

No.

1 : A client is prescribed epoetin alfa 8.00units subcutaneous three times per week. The medication is available in 20,000 units/mL. Determine how many mL the nurse will administer per dose. (Round to the nearest tenth)

2 : The nurse is providing post operative education for a client scheduled for a tympanoplasty. Which statement made by the client indicates that additional education is needed?

3 : The nurse is assessing a client with chronic obstructive pulmonary disease (COPD). The client is receiving oxygen at a flow rate of 5 liters per minute via nasal cannula. Which finding is most concerning?

4 : The nurse is preparing to administer medications and finds that the clients serum phenytoin level is 12 mcg/mL. What is the appropriate action by the nurse

5 : Nursing care of a patient with Grave's disease whose T3 & T4 are elevated would most likely include which activity?

6 : A client is admitted to the hospital for evaluation and treatment of thrombocytopenia. Which action is most important for the nurse to implement?

7 : Which client should the nurse assess first after receiving change of shift report?

8 : During an assessment, a Cushings patient tells the nurse she just looks awful and does not want anyone to be around her. Which would be the nurse best response?

9 : Which is appropriate to teach a patient following a posterior/lateral total hip replacement?

10 : In addition to sudden vision loss, the nurse would expect which clinical manifestation in a client with a detached retina?

1 :
A client is prescribed epoetin alfa 8.00units subcutaneous three times per week. The medication is available in 20,000 units/mL. Determine how many mL the nurse will administer per dose. (Round to the nearest tenth)

2 :
The nurse is providing post operative education for a client scheduled for a tympanoplasty. Which statement made by the client indicates that additional education is needed?

3 :
The nurse is assessing a client with chronic obstructive pulmonary disease (COPD). The client is receiving oxygen at a flow rate of 5 liters per minute via nasal cannula. Which finding is most concerning?

4 :
The nurse is preparing to administer medications and finds that the clients serum phenytoin level is 12 mcg/mL. What is the appropriate action by the nurse

5 :
Nursing care of a patient with Grave's disease whose T3 & T4 are elevated would most likely include which activity?

6 :
A client is admitted to the hospital for evaluation and treatment of thrombocytopenia. Which action is most important for the nurse to implement?

7 :
Which client should the nurse assess first after receiving change of shift report?

8 :
During an assessment, a Cushings patient tells the nurse she just looks awful and does not want anyone to be around her. Which would be the nurse best response?

9 :
Which is appropriate to teach a patient following a posterior/lateral total hip replacement?

10 :
In addition to sudden vision loss, the nurse would expect which clinical manifestation in a client with a detached retina?