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Rationale: Morphine can cause respiratory depression if given too much. Also you
should ALWAYS ASSESS the patient first when a med error is performed to make
sure med error doesn‟t put the client‟s health in risk.
4. A nurse is preparing to administer diphenhydramine 20 mg orally to a 6-year-old child who
has difficulty swallowing pills. Available is diphenhydramine 12.5 mg/5 mL oral syrup. Which
of the following images shows the correct # of mL the nurse should administer? (Round the
answer to the nearest whole number.)
Click on the syringe that has 8 mL of med.
20 img ixi(5mL/12.5mg) i= i8 imL
5. A nurse is caring for a 6-year-old child who has a new prescription for cefoxitin 80
mg/kg/day administered intravenously every 6 hour. The child weighs 20 kg. How much
cefoxitin should the nurse administer with each dose? (Round the answer to the nearest whole
number. Use a leading zero if it applies. Do not use a trailing zero.)
So it says each dose for the final answer, but we are given 80 mg/kg/day.
80 x 20 = (dose is given every 6 hours a day) =400 img
Rationale: 80 mg x 20 kg = 1,600 1,600/4 x day (q6h) = 400 mg
6. A nurse is preparing to administer IV fluids to a client. The nurse notes sparks when plugging
in the IV pump. Which of the following actions should the nurse take first?
a. Label the pump with a defective equipment sticker.
b. Unplugitheipump.
c. Obtain a replacement pump.
d. Notified the biomedical department to fix the pump.
Rationale: Prioritization question. YOU WILL FIRST UNPLUG the IV pump to avoid
causing a fire.
7. A nurse is caring for a client who has a surgical wound. Which of the following laboratory
values places the client at risk for poor wound healing?
a. Serumialbumini3 ig/dL
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b. Total lymphocyte count 2400 mm3
c. HCT 42%
d. HGB 16g/dL
Rationale: Albumin in low. Normal range is 3.5 to 5.5 g/dL. Low albumin places the
client at risk forpoor wound healing. The other lab values are within normal limits.
8. A nurse is preparing to check a client's blood pressure. Which of the following actions should
the nurse take? Chapter 27 Vitals signs page 244
a. Applyitheicuffiaboveitheiclient‟siantecubitalifossa.
b. Use a cuff with a width that is about 60% of the client's arm circumference. - width of the
cuff should be 40 % of arm circumference
c. How the clients sit with his arm resting above the level of his heart. - MUST BE AT
HEART LEVEL
d. Release the pressure on the client's arm 5 to 6 mm per second. - pressure release should
not be more than 2 to 3 mm hg per second
Rationale: ATI FUNDA says 40% of the arm circumference pg. 139. Release the
pressure no faster than 2 to 3 mm Hg per second. Apply the BP cuff 2.5 cm (1 in) above
the antecubital space with the brachial artery in line with the marking on the cuff.Apply
the BP cuff 2.5 cm (1 in) above the antecubital space with the brachial artery in line with
the marking on the cuff.
9. A nurse is preparing to perform nasal tracheal suctioning for a client. Which of the following
is an appropriate action for the nurse to take? Chapter 53 Airway management page 563
a. Hold the suction catheter with the clean non-dominant hand.
b. Apply suctioning for 20 to 30 seconds.- 10 -15 seconds is the maximum.
c. Place the catheter in a location that is clean and dry for later use new line.- NEVER
EVER REUSE THE SUCTION CATHETER . you throw it away after being used.
d. Use surgical asepsis when performing the procedure.- book say medical asepsis
which is maybe the same thing .
Rationale: sterile technique for trachea
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Rationale: Morphine can cause respiratory depression if given too much. Also you
should ALWAYS ASSESS the patient first when a med error is performed to make
sure med error doesn‟t put the client‟s health in risk.
4. A nurse is preparing to administer diphenhydramine 20 mg orally to a 6-year-old child who
has difficulty swallowing pills. Available is diphenhydramine 12.5 mg/5 mL oral syrup. Which
of the following images shows the correct # of mL the nurse should administer? (Round the
answer to the nearest whole number.)
Click on the syringe that has 8 mL of med.
20 img ixi(5mL/12.5mg) i= i8 imL
5. A nurse is caring for a 6-year-old child who has a new prescription for cefoxitin 80
mg/kg/day administered intravenously every 6 hour. The child weighs 20 kg. How much
cefoxitin should the nurse administer with each dose? (Round the answer to the nearest whole
number. Use a leading zero if it applies. Do not use a trailing zero.)
So it says each dose for the final answer, but we are given 80 mg/kg/day.
80 x 20 = (dose is given every 6 hours a day) =400 img
Rationale: 80 mg x 20 kg = 1,600 1,600/4 x day (q6h) = 400 mg
6. A nurse is preparing to administer IV fluids to a client. The nurse notes sparks when plugging
in the IV pump. Which of the following actions should the nurse take first?
a. Label the pump with a defective equipment sticker.
b. Unplugitheipump.
c. Obtain a replacement pump.
d. Notified the biomedical department to fix the pump.
Rationale: Prioritization question. YOU WILL FIRST UNPLUG the IV pump to avoid
causing a fire.
7. A nurse is caring for a client who has a surgical wound. Which of the following laboratory
values places the client at risk for poor wound healing?
a. Serumialbumini3 ig/dL
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b. Total lymphocyte count 2400 mm3
c. HCT 42%
d. HGB 16g/dL
Rationale: Albumin in low. Normal range is 3.5 to 5.5 g/dL. Low albumin places the
client at risk forpoor wound healing. The other lab values are within normal limits.
8. A nurse is preparing to check a client's blood pressure. Which of the following actions should
the nurse take? Chapter 27 Vitals signs page 244
a. Applyitheicuffiaboveitheiclient‟siantecubitalifossa.
b. Use a cuff with a width that is about 60% of the client's arm circumference. - width of the
cuff should be 40 % of arm circumference
c. How the clients sit with his arm resting above the level of his heart. - MUST BE AT
HEART LEVEL
d. Release the pressure on the client's arm 5 to 6 mm per second. - pressure release should
not be more than 2 to 3 mm hg per second
Rationale: ATI FUNDA says 40% of the arm circumference pg. 139. Release the
pressure no faster than 2 to 3 mm Hg per second. Apply the BP cuff 2.5 cm (1 in) above
the antecubital space with the brachial artery in line with the marking on the cuff.Apply
the BP cuff 2.5 cm (1 in) above the antecubital space with the brachial artery in line with
the marking on the cuff.
9. A nurse is preparing to perform nasal tracheal suctioning for a client. Which of the following
is an appropriate action for the nurse to take? Chapter 53 Airway management page 563
a. Hold the suction catheter with the clean non-dominant hand.
b. Apply suctioning for 20 to 30 seconds.- 10 -15 seconds is the maximum.
c. Place the catheter in a location that is clean and dry for later use new line.- NEVER
EVER REUSE THE SUCTION CATHETER . you throw it away after being used.
d. Use surgical asepsis when performing the procedure.- book say medical asepsis
which is maybe the same thing .
Rationale: sterile technique for trachea
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