A client who weighs 175 pounds is receiving IV bolus dose of heparin 80 units/kg. The heparin is available in a 2 ml vial, labeled 10,000 units/ml. How many ml should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

Correct Answer: A

Rationale: In this pharmacology question, the correct answer is A) 0.6 ml. To calculate the correct dosage, the nurse first needs to determine the client's weight in kilograms (175 lbs ÷ 2.2 = 79.5 kg). Then, the nurse calculates the heparin dose by multiplying the weight in kg by the prescribed dose (80 units/kg x 79.5 kg = 6,360 units). Next, the nurse needs to determine how many ml of the 10,000 units/ml heparin vial to administer (6,360 units ÷ 10,000 units/ml = 0.636 ml). Rounding to the nearest tenth, the nurse should administer 0.6 ml. Option B) 0 is incorrect because the nurse should administer a dose of heparin based on the client's weight and the prescribed dosage. Option C) 6 is incorrect because it represents the total units of heparin required, not the volume in ml that should be administered. Option D) 1 is incorrect as it does not accurately reflect the calculated dose based on the client's weight and the concentration of the heparin vial. This question provides essential pharmacological calculations for pediatric nursing students. Understanding how to calculate medication dosages based on a client's weight and available concentrations is crucial for safe and effective pediatric patient care. This scenario also reinforces the importance of accurate dosage calculations to prevent medication errors and ensure optimal patient outcomes.

Correct Answer: C

Rationale: In this scenario, the correct action for the nurse to implement is to measure the patient's pulse and blood pressure (Option C). This is crucial because the patient is experiencing symptoms of weakness and jitteriness, which could indicate hypoglycemia, a common complication in diabetes management. Checking the pulse and blood pressure can help assess the patient's hemodynamic status and provide valuable information about his overall condition. Option A (Checking his fingerstick glucose level) could also be important in this situation to confirm if the patient's symptoms are indeed related to hypoglycemia. However, measuring the pulse and blood pressure takes precedence as it provides immediate data on the patient's cardiovascular status, especially during a perioperative period. Options B (Assessing his skin temperature and moisture) and D (Documenting anxiety on the surgical checklist) are not the most appropriate actions to take in response to the patient's symptoms. While assessing skin temperature and moisture can provide some information about the patient's perfusion status, it may not directly address the immediate concern of weakness and jitteriness. Documenting anxiety, although important for holistic care, does not address the physiological symptoms the patient is experiencing and should not be the priority in this situation. From an educational perspective, this scenario highlights the importance of prioritizing nursing actions based on the patient's presenting symptoms and clinical context. Understanding the significance of assessing vital signs in a timely manner, especially in patients with comorbid conditions like diabetes, is crucial for providing safe and effective care. It also underscores the need for nurses to be adept at recognizing and managing potential complications in patients with chronic illnesses undergoing surgical procedures.

Correct Answer: D

Rationale: In this scenario, the most immediate action by the nurse should be prompted by the further decline in the level of consciousness (Option D). This is crucial because a worsening level of consciousness can indicate a deterioration in the client's condition, potentially leading to life-threatening complications. In pediatric patients, changes in mental status are critical indicators of systemic compromise and require immediate attention to prevent adverse outcomes. Option A, facial puffiness and periorbital edema, are common symptoms of hypothyroidism and may not require immediate action unless severe or accompanied by other concerning signs. Option B, a hematocrit of 30%, while low, may not be the most immediate concern compared to a declining level of consciousness. It could indicate anemia, which should be addressed but is not as urgent as a neurological deterioration. Option C, cold and dry skin, is also a symptom of hypothyroidism and may not warrant immediate action unless it is severe and contributing to the decline in the client's condition. In an educational context, understanding the prioritization of assessments and interventions based on the urgency of the client's condition is vital in pediatric nursing. This case highlights the importance of recognizing changes in consciousness as a red flag requiring immediate attention to prevent further deterioration and ensure optimal patient outcomes.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Pain. The probable etiology of the male client's difficulty sleeping is pain caused by Herpes zoster (shingles) lesions on his thorax. Pain associated with shingles can be intense and persistent, making it challenging for the client to find a comfortable position to sleep. This pain can disrupt the client's ability to fall asleep or stay asleep, leading to sleep disturbances. Option B) Nocturia, which is excessive urination at night, is not likely to be the cause of the client's sleep difficulty in this case. Option C) Dyspnea, which is difficulty breathing, and Option D) Frequent cough are also not relevant to the client's complaint of difficulty sleeping due to shingles-related pain. Educationally, understanding the impact of pain on sleep is crucial for nurses caring for clients with conditions like Herpes zoster. Nurses need to assess and manage pain effectively to promote quality sleep, which is essential for the client's overall well-being and recovery. By recognizing pain as a potential barrier to sleep, nurses can implement appropriate interventions to improve the client's comfort and rest.

Correct Answer: C

Rationale: In this scenario, the correct answer is option C: "Observe for prolonged periods of apnea." The nurse's first priority during a seizure is to ensure the client's airway remains clear and that they are breathing adequately. Prolonged periods of apnea can lead to hypoxia, which can be life-threatening. By closely monitoring the client's breathing, the nurse can intervene promptly if respiratory distress occurs. Option A, documenting details of the seizure activity, is important for the client's medical record but is not the most immediate concern during an active seizure. Option B, observing for lacerations to the tongue, is important post-seizure to assess for injuries but is not the priority during the seizure itself. Option D, evaluating for evidence of incontinence, is also a secondary concern compared to ensuring the client's airway and breathing are stable. In an educational context, this question highlights the critical importance of prioritizing interventions during a medical emergency like a seizure. Nurses must be prepared to act quickly and decisively to ensure the safety and well-being of their clients, especially when faced with unexpected situations. Understanding the priorities of care during a seizure is crucial knowledge for nurses working in various healthcare settings, including pediatric nursing where seizures can occur.