Question

A nurse is preparing to administer lorazepam 0.044 mg/kg IV bolus to a client who weighs 50 kg (110 lb). The amount available is lorazepam injection 4 mg/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 :

🧮The nurse must first calculate the total ordered dose by multiplying 0.044 mg/kg by the client's 50-kg weight, which yields 2.2 mg, demonstrating the importance of accurate medication calculation.

💉The available concentration is 4 mg/mL, so the nurse performs 2.2 mg ÷ 4 mg/mL, resulting in 0.55 mL, which rounds to 0.6 mL, emphasizing correct dose conversion.

📏Using a leading zero prevents medication errors, highlighting a crucial safety practice in clinical pharmacology.

⚠️Rounding to the nearest tenth ensures precise delivery of the ordered medication for safe client care.

📌Core Message

The nurse ensures safe administration by applying accurate medication calculation using weight-based dosing and available concentration.

Answer 2

Correct Answers:

“A 2 centimeter by 2-centimeter amount of purulent drainage was noted during a dressing change."

Rationale :

📝This statement provides objective data, which is a required element of proper clinical documentation.

📏The entry avoids judgmental language, which aligns with essential professional standards of charting.

🩺The nurse describes measurable and observable assessment findings, supporting accurate communication within the healthcare team.

⚖️This wording reduces risk of legal liability by ensuring factual and non-interpretive documentation.

📌Core Message

Accurate charting requires strictly objective documentation to support clear and professional communication.

Answer 3

Correct Answers:

Instruct client to use sugarless gum or hard candy.
Instruct the client to continue taking clozapine.
Educate client to have neutrophil count drawn every month.

Rationale :

🧠Clozapine can cause anticholinergic effects such as dry mouth, so sugarless gum helps manage this adverse effect safely.

🩺Stopping clozapine abruptly can worsen schizophrenia symptoms, making continuation essential for maintaining psychiatric stability.

⚠️A declining absolute neutrophil count—now at 1,500/mm³—requires strict monthly monitoring because clozapine can cause agranulocytosis, a serious safety concern.

📉The weight gain and abdominal changes relate to metabolic effects, but monitoring neutrophils remains the top priority for maintaining treatment safety.

📌Core Message

Clients taking clozapine require education focused on managing anticholinergic effects and maintaining essential neutrophil monitoring.

Answer 4

Correct Answers

Blank 1 Correct Option: Lithium toxicity
Blank 2 Correct Option: Sodium level

Rationale :

💧A low sodium level (132 mEq/L) increases renal reabsorption of lithium, raising the risk for lithium toxicity, a dangerous complication.

🧠The client's manic behavior and poor intake can worsen dehydration, further concentrating lithium levels in the bloodstream.

📉The recorded lithium level of 0.6 mEq/L is subtherapeutic, but the physiologic trend of declining sodium raises future toxicity risk.

⚠️Lithium and sodium have a direct relationship, making hyponatremia a critical factor in predicting drug toxicity.

📌Core Message

A low sodium level increases the risk of lithium toxicity, requiring close monitoring during treatment.

Answer 5

Correct Answers:

"Clients can appoint a health care surrogate for when they are unable to make decisions."

Rationale :

📋Clients with schizophrenia maintain legal rights to create advance directives, including naming a health-care surrogate.

👥This option supports client autonomy, which remains intact unless legally removed by a court.

⚖️The statement aligns with legal expectations surrounding decision-making capacity, which is not automatically restricted in schizophrenia.

🧠Advance directives empower clients to express their preferences despite chronic mental illness, promoting ethical care.

📌Core Message

Clients with schizophrenia retain the right to appoint a health-care surrogate through advance directives.

Answer 6

Correct Answers:

Serum alpha-fetoprotein levels can assist in identifying neural tube defects.

Rationale :

🧬Serum alpha-fetoprotein testing is performed during early pregnancy to screen for neural tube defects, a key congenital concern.

📈Abnormally high AFP levels may indicate defects such as spina bifida, reinforcing the importance of early prenatal screening.

🔬This test is appropriate during the first trimester for clients with a family history of chromosomal abnormalities, aiding risk evaluation.

⚕️The other listed tests do not relate to neural tube detection or are scheduled at incorrect gestational ages.

📌Core Message

Maternal alpha-fetoprotein screening helps identify potential neural tube defects early in pregnancy.

Answer 7

Correct Answers:

Wear gloves when washing dishes.

Rationale :

🧤Chemotherapy-induced peripheral neuropathy reduces sensation, making protection from thermal injury essential when using hot water.

⚠️Clients with neuropathy are at increased risk of burns, so protective gloves maintain skin safety.

🦶Loose-fitting shoes increase fall and injury risk due to diminished proprioception, showing why they are unsafe.

👣Frequent foot inspection supports injury prevention, but weekly checks are insufficient for compromised sensation.

📌Core Message

Peripheral neuropathy requires protective behaviors that prevent thermal injury and enhance safety.

Answer 8

Correct Answers:

Absent bowel sounds

Rationale :

🚫Morphine is contraindicated in clients with absent bowel sounds because opioids reduce peristalsis, worsening potential obstruction.

⚠️Administering morphine in this situation can cause severe gastrointestinal complications, making this the highest-priority finding.

🩺A respiratory rate of 14/min and blood pressure of 100/60 are within acceptable ranges for opioid administration, showing they are not contraindications.

💧Urine output of 100 mL/hr reflects adequate renal perfusion, meaning it does not restrict opioid use.

📌Core Message

Morphine must be withheld when a client has absent bowel sounds due to risk of worsening intestinal obstruction.

Answer 9

Correct Answers:

Bradypnea

Rationale :

💤Hypermagnesemia depresses neuromuscular activity, leading to bradypnea, a hallmark respiratory manifestation.

⚠️Magnesium acts as a central nervous system depressant, slowing respiratory effort as serum levels rise.

🩺Other symptoms such as personality change or cardiac abnormalities occur with different electrolyte disturbances, not classic hypermagnesemia.

❤️Peaked T-waves are associated with hyperkalemia, not excess magnesium.

📌Core Message

Hypermagnesemia commonly causes bradypnea due to depressed neuromuscular function.

Answer 10

Correct Answers:

Enoxaparin 30 mg subcut every 12 hr

Rationale :

📝This documentation uses the correct abbreviation for milligrams and the accepted spelling of subcut, promoting safe communication.

⚕️It avoids unsafe abbreviations such as SC, SQ, or q HS, which can cause medication-related errors.

📋The time interval of every 12 hr is clearly written, supporting precise administration timing.

⚠️Using unapproved abbreviations increases risk of misinterpretation, making the chosen option the safest.

📌Core Message

Clear medication orders require standardized notation to prevent administration errors and ensure safe communication.

📌Core Message

2 :
A nurse manager is teaching a newly licensed nurse about documenting information in a client's medical record. Which of the following entries the newly licensed nurse indicates an understanding of the teaching?

📌Core Message

3 :
A nurse in an outpatient mental health clinic is caring for a client.

Answer Options

📌Core Message

4 :
A nurse on a mental health unit is caring for a client.

Correct Answers

📌Core Message

5 :
A nurse about advance directives for clients who have schizophrenia. Which of the following statements by t newly licensed nurse indicates an understanding of the teaching?

📌Core Message

6 :
A nurse is discussing various options for prenatal testing with a client who is at 7 weeks of gestation and has a family history of chromosomal abnormalities. Which of the following information should the nurse include?

📌Core Message

7 :
A nurse is educating a client who has chemotherapy-induced peripheral neuropathy. Which of the following information should the nurse include in the teaching?

📌Core Message

8 :
A nurse is assessing a client prior to administering morphine. Which of the following findings should the nurse identify as a contraindication to administration of this medication?

📌Core Message

9 :
A nurse is planning to teach a group of newly licensed nurses about hypermagnesemia. Which of the following manifestations should the nurse include in the teaching?

📌Core Message

10 :
A nurse is transcribing a new prescription in a client's medical record for enoxaparin 30 milligrams, subcutaneously every 12 hours. Which of the following documentation should the nurse use?

📌Core Message

📌Core Message

2 : A nurse manager is teaching a newly licensed nurse about documenting information in a client's medical record. Which of the following entries the newly licensed nurse indicates an understanding of the teaching?

📌Core Message

3 : A nurse in an outpatient mental health clinic is caring for a client.

Answer Options

📌Core Message

4 : A nurse on a mental health unit is caring for a client.

Correct Answers

📌Core Message

5 : A nurse about advance directives for clients who have schizophrenia. Which of the following statements by t newly licensed nurse indicates an understanding of the teaching?

📌Core Message

6 : A nurse is discussing various options for prenatal testing with a client who is at 7 weeks of gestation and has a family history of chromosomal abnormalities. Which of the following information should the nurse include?

📌Core Message

7 : A nurse is educating a client who has chemotherapy-induced peripheral neuropathy. Which of the following information should the nurse include in the teaching?

📌Core Message

8 : A nurse is assessing a client prior to administering morphine. Which of the following findings should the nurse identify as a contraindication to administration of this medication?

📌Core Message

9 : A nurse is planning to teach a group of newly licensed nurses about hypermagnesemia. Which of the following manifestations should the nurse include in the teaching?

📌Core Message

10 : A nurse is transcribing a new prescription in a client's medical record for enoxaparin 30 milligrams, subcutaneously every 12 hours. Which of the following documentation should the nurse use?

📌Core Message

2 :
A nurse manager is teaching a newly licensed nurse about documenting information in a client's medical record. Which of the following entries the newly licensed nurse indicates an understanding of the teaching?

3 :
A nurse in an outpatient mental health clinic is caring for a client.

4 :
A nurse on a mental health unit is caring for a client.

5 :
A nurse about advance directives for clients who have schizophrenia. Which of the following statements by t newly licensed nurse indicates an understanding of the teaching?

6 :
A nurse is discussing various options for prenatal testing with a client who is at 7 weeks of gestation and has a family history of chromosomal abnormalities. Which of the following information should the nurse include?

7 :
A nurse is educating a client who has chemotherapy-induced peripheral neuropathy. Which of the following information should the nurse include in the teaching?

8 :
A nurse is assessing a client prior to administering morphine. Which of the following findings should the nurse identify as a contraindication to administration of this medication?

9 :
A nurse is planning to teach a group of newly licensed nurses about hypermagnesemia. Which of the following manifestations should the nurse include in the teaching?

10 :
A nurse is transcribing a new prescription in a client's medical record for enoxaparin 30 milligrams, subcutaneously every 12 hours. Which of the following documentation should the nurse use?