A nurse receives a telephone prescription from the provider, who states, "Four milligrams of morphine diluted with five milliliters of sterile water, intravenously each morning at nine o'clock before client dressing changes." Which of the following entries by the nurse indicates correct transcription of the prescription?

MSO4 4 mg IV bolus daily before dressing changes and dilute with 5 cc of water.

Morphine 4 mg IV bolus daily at 0900 before dressing changes, dilute medication with 5 mL of sterile water.

Morphine 4 mg IV bolus Q.D. before dressing changes and dilute with 5 cc of sterile water.

MSO4 4 mg IV bolus daily @9 AM, dilute with 5 mL of sterile water.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

While the abbreviation "MSO4" represents morphine sulfate, it is safer to spell out the medication name to prevent misinterpretation. Also, the use of "cc" for volume and lack of clarity in timing make this option less desirable.

Choice B rationale:

(Correct Choice) This option correctly identifies the medication, includes the dose (4 mg), specifies the route (IV), indicates the timing (daily at 0900 before dressing changes), and provides instructions for dilution (5 mL of sterile water).

Choice C rationale:

Using "Q.D." is an abbreviation for "every day" and might lead to confusion due to unfamiliarity. Additionally, using "cc" instead of "mL" and lack of clarity in timing reduce the accuracy of this transcription.

Choice D rationale:

Using "MSO4" and "cc" are potential sources of confusion. Also, the abbreviation "@9 AM" might not be universally understood, and "mL" is a more appropriate unit for volume.

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Correct Answer is A

Explanation

To calculate how many milliliters (mL) of diazepam oral solution should be administered, you can use the following formula:

Dose (mL) = Desired dose (mg) / Concentration (mg/mL)

In this case, the desired dose is 2 mg, and the concentration of the diazepam oral solution is 5 mg/1 mL.

Dose (mL) = 2 mg / 5 mg/mL = 0.4 mL

So, the nurse should administer 0.4 mL of diazepam oral solution with each dose. The correct answer is:

A) 0.4 mL.

A. Apply the skin sealant on damp skin. B. Remove the appliance before emptying the pouch. C. Ensure that the skin is slightly damp for better adhesion of the pouch. D. Trace the size of stoma onto the skin barrier.

Correct Answer is D

Explanation

Choice A rationale:

Apply the skin sealant on damp skin. Rationale: Applying skin sealant on damp skin is not the recommended approach for securing an ostomy appliance. It's important to ensure that the skin is clean and dry before applying the sealant or the skin barrier. Moisture can compromise adhesion and lead to skin irritation or appliance detachment.

Choice B rationale:

Remove the appliance before emptying the pouch. Rationale: Removing the appliance before emptying the pouch is not a necessary step when changing an ostomy appliance. Typically, the pouch can be emptied without removing the entire appliance, which helps maintain the seal and reduces unnecessary skin exposure.

Choice C rationale:

Ensure that the skin is slightly damp for better adhesion of the pouch. Rationale: Ensuring that the skin is slightly damp is not advisable for better adhesion of the pouch. The skin should be completely dry before applying the pouch to ensure proper adhesion. Moisture on the skin can lead to leakage or detachment of the appliance.

Choice D rationale:

Trace the size of stoma onto the skin barrier. Rationale: This choice is the correct answer because tracing the size of the stoma onto the skin barrier ensures a precise fit, which is crucial for preventing leaks and maintaining the integrity of the ostomy. A proper fit also helps in preventing skin irritation and discomfort. Choosing the correct barrier size based on the stoma's dimensions is a key aspect of effective ostomy care.

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer diazepam 2 mg twice daily via NG tube. Available is diazepam oral solution 5 mg/1 mL. How many mL should the nurse administer with each dose?

Correct Answer is A

Explanation

A nurse is providing teaching to a client who has a new colostomy. Which of the following actions should the nurse take when demonstrating how to change the ostomy appliance?

Correct Answer is D

Explanation

A nurse is leaving a client's isolation room. Which of the following pieces of personal protective equipment (PPE) should the nurse remove first?

A nurse is caring for a client who is at risk for pressure injury formation due to immobility. The nurse should place the client in which of the following positions to reduce pressure on the client's bony prominences?

A nurse is completing a preadmission interview for a client who is to undergo surgery the following day. The client reports a latex allergy. Which of the following interventions should the nurse include when planning care for the client's surgery? (Select all that apply)

A nurse is caring for a group of clients. Which of the following client-care situations requires the nurse to complete an incident report?

A nurse is providing discharge teaching to a client who will be using a cane to maintain mobility at home following a left knee arthroplasty. Which of the following statements by the client indicates an understanding of the safe use of a cane?

A nurse is assisting a coworker with moving a client up in bed using a draw sheet. Which of the following actions should the nurse take?

A nurse is providing teaching to an older adult client who has kyphosis and osteoporosis. Which of the following client statements indicates an understanding of the teaching?

A nurse is caring for a client who has a temperature of 40°C (104°F). Which of the following interventions should the nurse take?