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Questions 149

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Question 1 of 5

The physician has ordered Vancocin (vancomycin) 500 mg IV every 6 hours for a client with MRSA. The medication should be administered:

Correct Answer: D

Rationale: Vancomycin should be infused over at least 60 minutes to prevent adverse reactions such as red man syndrome.

Question 2 of 5

The nurse is inserting an intravenous line into the right arm and has identified a potential insertion site. Place the steps (indicated in Roman numerals) of venipuncture in the proper sequential order.

Order the Items

Source Container

Palpate vein.
Cleanse skin
Apply tourniquet.
Perform venipuncture.

Correct Answer: C,A,B,D

Rationale: Venipuncture sequence: Apply tourniquet (III), palpate vein (I), cleanse skin (II), perform venipuncture (IV).

Question 3 of 5

A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is:

Correct Answer: C

Rationale: Post-tonsillectomy, the risk of bleeding and aspiration is a priority due to the surgical site in the throat.

Question 4 of 5

Which statement is true regarding the infant's susceptibility to pertussis?

Correct Answer: B

Rationale: Infants are highly susceptible to pertussis from birth, as maternal immunity is minimal, and severe cases are common in this age group.

Question 5 of 5

The nurse is making a home visit to an elderly client during the summer. Upon arrival, the nurse notices the refrigerator and freezer doors are open as the client is using both for air conditioning. Which of the following actions by the nurse are most appropriate?

Correct Answer: B

Rationale: Discussing the risks (e.g., food spoilage, electrical hazards) with the client and family promotes safety and education.

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