Question

A client is receiving phenytoin 0.2 gram orally twice daily. The medication is available in 100 mg capsules. How many capsules should the nurse administer? (Enter numeric value only.)

Answer 1

Correct Answers:

2

Rationale :

🧮Phenytoin 0.2 grams is equivalent to 200 mg, as 1 gram = 1,000 mg.

🧾The available capsule strength is 100 mg, so the nurse must administer 200 ÷ 100 = 2 capsules per dose.

📏Administering the correct dose conversion ensures therapeutic levels and avoids toxicity or underdosing.

💊Accurate calculation is critical for antiepileptic drugs like phenytoin, which have a narrow therapeutic index.

📌Core Message

Accurate medication dose calculation based on metric conversions and available strengths is essential for safe medication administration.

Answer 2

Correct Answers:

Decrease speaking speed.

Rationale :

🦻Older adults often experience presbycusis, which affects the ability to hear high-frequency sounds, not just volume.

🗣️Decreasing the speaking speed allows the client time to process spoken words, improving communication effectiveness.

🙅‍♀️Shouting or over-enunciating can distort sounds and make it more difficult for the client to understand speech.

👂Effective communication requires adjusting for hearing deficits using clear, slow, and low-pitched speech.

📌Core Message

Clear communication with older adults often requires slower speech patterns rather than increased volume or exaggerated expressions.

Answer 3

Correct Answers:

Hematuria.

Rationale :

🩸Hematuria is a sign of possible renal involvement, such as lupus nephritis, which is a life-threatening complication of systemic lupus erythematosus (SLE).

⚠️This finding requires immediate follow-up to prevent irreversible kidney damage or renal failure.

🦴Fatigue, alopecia, and joint pain are common manifestations of SLE but are not immediate threats to organ function.

🩺Prompt identification of organ-threatening complications is crucial in autoimmune disorders like SLE.

📌Core Message

Hematuria in SLE warrants urgent evaluation due to the risk of renal complications like lupus nephritis.

Answer 4

Correct Answers:

Swallowing ability.

Rationale :

😶A mask-like face in Parkinson’s disease can indicate decreased facial muscle movement, which can impair swallowing.

🚫This places the client at high risk for aspiration, which can lead to pneumonia and other respiratory complications.

💁‍♂️Assessing respiratory rate is important but less immediate than identifying dysphagia risks.

🍴Early evaluation of swallowing ability ensures timely interventions such as diet modifications or speech therapy.

📌Core Message

In Parkinson’s disease, a mask-like face suggests possible dysphagia, making swallowing assessment the highest priority.

Answer 5

Correct Answers:

Complete blood count.

Rationale :

🩸Fatigue in a client with pernicious anemia suggests possible worsening of anemia, best assessed by a complete blood count (CBC).

💉Although the client receives B12 injections, a CBC will show if they are effective or if there is another underlying issue.

🧪MCV and Hgb/Hct levels on the CBC will help confirm macrocytic anemia characteristic of B12 deficiency.

🔍Other labs like liver enzymes and electrolytes are less directly linked to oxygen-carrying capacity and fatigue symptoms.

📌Core Message

A CBC is essential to evaluate the effectiveness of B12 therapy and investigate ongoing fatigue in pernicious anemia.

Answer 6

Correct Answers:

0.5

Rationale :

📏The ordered dose is 10 mcg, and the concentration is 0.02 mg/mL.

🔄Convert 0.02 mg = 20 mcg, so 10 ÷ 20 = 0.5 mL.

💉Administering the correct volume ensures proper opioid reversal with naloxone without exceeding the dose.

⚖️Precise unit conversion from mg to mcg is critical to avoid medication errors.

📌Core Message

Administering naloxone safely requires precise unit conversions and volume calculations based on mcg dosage.

Answer 7

Correct Answers:

Insert a nasogastric tube (NGT) and attach to low intermittent suction (LIS).

Rationale :

🤢Dark brown emesis in the setting of bowel cancer suggests a possible bowel obstruction, requiring immediate gastric decompression.

🧯An NGT to LIS helps relieve pressure, reduce vomiting, and prevent aspiration.

🖼️Abdominal x-ray can follow but is not the immediate intervention for active symptoms.

💊Administering pain medication or inserting a Foley catheter is supportive but not problem-solving in this scenario.

📌Core Message

Vomiting dark emesis in suspected bowel obstruction warrants immediate NG tube insertion to prevent complications.

Answer 8

Correct Answers:

The client's skin on the shins will be intact at the next clinic visit.

Rationale :

🚶‍♂️Intermittent claudication reflects peripheral arterial disease (PAD), increasing the risk for skin breakdown due to poor perfusion.

💉A key nursing goal is maintaining intact skin to prevent ulcers and infections.

🧬While glucose control and family education are important, preserving tissue integrity directly addresses the circulatory deficit.

⚠️PAD-related wounds can progress quickly to necrosis or amputation if not prevented.

📌Core Message

For clients with intermittent claudication, maintaining intact skin reflects effective management of circulatory complications.

Answer 9

Correct Answers:

The client will adhere to the medication regimen after discharge.

Rationale :

💉Post-op clients with new insulin requirements must demonstrate understanding and compliance with self-administration for safety.

🏷️The outcome focuses on long-term self-care and adherence, which is key after transitioning from oral to injectable therapy.

🧼Ostomy care and auscultating breath sounds are important but not the primary behavioral outcome in this context.

📦A well-written outcome should reflect client-centered behavioral changes and self-management skills.

📌Core Message

For post-op clients with new insulin regimens, focus on promoting adherence to ensure safe self-management after discharge.

Answer 10

Correct Answers:

A barrel chest results because of using a hyperventilating breathing pattern.

Rationale :

📦A barrel chest is a hallmark of emphysema, resulting from chronic air trapping in the overdistended alveoli.

💨The client uses increased respiratory effort, including hyperventilation, to compensate for impaired gas exchange.

📉The lungs lose their elasticity, leading to chest wall remodeling that results in the barrel-shaped appearance.

🧍This physical change is a result of prolonged use of accessory muscles, not necessarily increased tolerance or decreased oxygen demand.

📌Core Message

Chronic hyperinflation of alveoli in emphysema causes a barrel chest due to chest wall expansion.

1 :
A client is receiving phenytoin 0.2 gram orally twice daily. The medication is available in 100 mg capsules. How many capsules should the nurse administer? (Enter numeric value only.)

2 :
An older adult female client is hospitalized with a fractured femur. During a routine nursing assessment, she repeatedly asks the nurse to "speak up" so that she can hear the questions. Which action is best for the nurse to take?

3 :
The nurse completes the admission assessment of a client with systemic lupus erythematosus. Which finding requires immediate follow up by the nurse?

4 :
The nurse observes that a newly admitted client with Parkinson's disease exhibits a mask like facial appearance. Which additional nursing assessment takes priority in response to this finding?

5 :
A client with pernicious anemia takes supplemental folate and self-administers monthly vitamin B12 injections. The client reports feeling increasingly fatigued. Which laboratory value should the nurse review?

6 :
The healthcare provider (HCP) prescribes naloxone HCl 10 mcg IV bolus stat. Naloxone HCL is supplied as "0.02 mg/ml." How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

8 :
The nurse is developing a plan of care (POC) for a client with type 2 diabetes mellitus (DM) who reports intermittent claudication in the legs. Which outcome should the nurse include in the POC for this client?

10 :
An adult client who has been diagnosed with emphysema asks the nurse to talk about the symptoms of the disease. Which statement should be included in the nurse's description of emphysema?

1 : A client is receiving phenytoin 0.2 gram orally twice daily. The medication is available in 100 mg capsules. How many capsules should the nurse administer? (Enter numeric value only.)

2 : An older adult female client is hospitalized with a fractured femur. During a routine nursing assessment, she repeatedly asks the nurse to "speak up" so that she can hear the questions. Which action is best for the nurse to take?

3 : The nurse completes the admission assessment of a client with systemic lupus erythematosus. Which finding requires immediate follow up by the nurse?

4 : The nurse observes that a newly admitted client with Parkinson's disease exhibits a mask like facial appearance. Which additional nursing assessment takes priority in response to this finding?

5 : A client with pernicious anemia takes supplemental folate and self-administers monthly vitamin B12 injections. The client reports feeling increasingly fatigued. Which laboratory value should the nurse review?

6 : The healthcare provider (HCP) prescribes naloxone HCl 10 mcg IV bolus stat. Naloxone HCL is supplied as "0.02 mg/ml." How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

8 : The nurse is developing a plan of care (POC) for a client with type 2 diabetes mellitus (DM) who reports intermittent claudication in the legs. Which outcome should the nurse include in the POC for this client?

10 : An adult client who has been diagnosed with emphysema asks the nurse to talk about the symptoms of the disease. Which statement should be included in the nurse's description of emphysema?

1 :
A client is receiving phenytoin 0.2 gram orally twice daily. The medication is available in 100 mg capsules. How many capsules should the nurse administer? (Enter numeric value only.)

2 :
An older adult female client is hospitalized with a fractured femur. During a routine nursing assessment, she repeatedly asks the nurse to "speak up" so that she can hear the questions. Which action is best for the nurse to take?

3 :
The nurse completes the admission assessment of a client with systemic lupus erythematosus. Which finding requires immediate follow up by the nurse?

4 :
The nurse observes that a newly admitted client with Parkinson's disease exhibits a mask like facial appearance. Which additional nursing assessment takes priority in response to this finding?

5 :
A client with pernicious anemia takes supplemental folate and self-administers monthly vitamin B12 injections. The client reports feeling increasingly fatigued. Which laboratory value should the nurse review?

6 :
The healthcare provider (HCP) prescribes naloxone HCl 10 mcg IV bolus stat. Naloxone HCL is supplied as "0.02 mg/ml." How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

8 :
The nurse is developing a plan of care (POC) for a client with type 2 diabetes mellitus (DM) who reports intermittent claudication in the legs. Which outcome should the nurse include in the POC for this client?

10 :
An adult client who has been diagnosed with emphysema asks the nurse to talk about the symptoms of the disease. Which statement should be included in the nurse's description of emphysema?