A client is to receive 250,000 units of benzathine penicillin.
G. The medication is available in a vial containing 300,000 units per milliliter. How many milliliters should a nurse administer?

Using an automatic BP cuff with a shivering client with a history of an irregular heart rate can result in inaccurate and low readings.

This is because shivering can interfere with the cuff inflation and deflation, and an irregular heart rate can affect the accuracy of the device.

The nurse should intervene and use a manual BP cuff with a stethoscope instead.

Choice B is wrong because pulling the client’s ear pinna backward, up and out to obtain a tympanic membrane temperature is the correct technique for adults and older children. This helps to straighten the ear canal and allow the light to reflect on the tympanic membrane, which shares the same vascular artery as the hypothalamus.

Choice C is wrong because counting the client’s radial pulse who is supine with the forearm straight alongside the body is an appropriate method.

The radial pulse can be easily palpated at the wrist, and the supine position and straight forearm do not affect the pulse rate.

Choice D is wrong because counting the respirations for one full minute for a client with tachypnea is a recommended practice.

Tachypnea means rapid breathing, and counting for one full minute can ensure accuracy and detect any variations in the respiratory pattern.

This is because a client with obstructive sleep apnea (OSA) may have periods of apnea lasting more than 10 seconds during sleep, which can lead to hypoxia and hypercapnia. These conditions can cause the client to be difficult to arouse and may indicate respiratory failure.

The nurse should take immediate action to stimulate the client, provide oxygen, and call for help.

Choice B is wrong because blood pressure 142/92 mmHg is not an emergency for a client with OSA. It is within the stage 1 hypertension range, which may be caused by OSA or other factors. The nurse should monitor the client’s blood pressure and encourage lifestyle modifications, such as weight loss, exercise, and dietary changes.

Choice C is wrong because apneic periods lasting more than 10 seconds are expected in a client with OSA. This is the criterion for diagnosing OSA during a sleep study. The nurse should educate the client about the use of continuous positive airway pressure (CPAP) or other treatments to prevent apnea and improve oxygenation during sleep.

Choice D is wrong because oxygen desaturation to 90% when asleep is not an emergency for a client with OSA. It is a common finding in OSA due to the intermittent obstruction of the upper airway. The nurse should ensure that the client has supplemental oxygen available and teach the client about the benefits of CPAP or other devices to maintain airway patency and oxygen saturation during sleep.