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Question 1 of 5

The physician prescribes phenytoin (Dilantin) for a client with seizure disorders. Phenytoin can only be mixed with which of the following solutions?

Correct Answer: D

Rationale: Phenytoin is compatible only with normal saline and should be mixed only with normal saline for administration.

Question 2 of 5

The client is receiving a continuous infusion of propofol (Diprivan) for sedation. Which assessment is most important?

Correct Answer: A

Rationale: Propofol can cause respiratory depression, so monitoring respiratory rate is critical to detect apnea or hypoventilation. Blood pressure, pulse, and temperature are monitored but are less immediate concerns.

Question 3 of 5

A client with a history of lymphoma is admitted with complaints of night sweats. The nurse should expect the client to have:

Correct Answer: A

Rationale: Night sweats are a B symptom of lymphoma, along with fever and weight loss, indicating systemic disease.

Question 4 of 5

One of the most reliable assessment tools for adequacy of fluid resuscitation in burned children is:

Correct Answer: B

Rationale: Blood pressure can remain normotensive in a state of hypovolemia. Capillary refill, alterations in sensorium, and urine output are the most reliable indicators for assessing hydration. Skin turgor is not a reliable indicator for assessing hydration in a burn client. Fluid intake does not indicate adequacy of fluid resuscitation in a burn client.

Question 5 of 5

Which statement made by the student nurse indicates the need for further teaching regarding the administration of heparin?

Correct Answer: D

Rationale: Heparin is administered subcutaneously without aspiration, as aspirating can cause tissue damage and increase bleeding risk. The other statements are correct: heparin is injected 1–2 inches from the umbilicus, massage is avoided to prevent hematoma, and PTT is monitored to assess therapeutic effect.

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