Order: Diazepam 4 mg via nasogastric tube three times daily. Available: Diazepam oral solution 5 mg per 5 mL. How many milliliters should the client receive per dosage?

2 mL

4 mL

5 mL

6 mL

Answer and Explanation

The Correct Answer is B

Choice A reason: 2 mL provides 2 mg (5 mg/5 mL = 1 mg/mL, so 2 mL = 2 mg), which is half the ordered 4 mg. This underdoses the patient, making it incorrect for the prescribed dosage.

Choice B reason: Diazepam 5 mg/5 mL means 1 mg/mL. For 4 mg, 4 mL is needed (4 mg ÷ 1 mg/mL = 4 mL). This delivers the correct dose, making 4 mL the correct answer.

Choice C reason: 5 mL delivers 5 mg (5 mg/5 mL), exceeding the ordered 4 mg. This overdoses the patient, risking sedation, making 5 mL incorrect for the prescribed dosage.

Choice D reason: 6 mL delivers 6 mg, significantly exceeding the 4 mg order. This overdose increases side effects like respiratory depression, making 6 mL incorrect for the correct dosage.

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Correct Answer is C

Explanation

Choice A reason: Placing a blanket over the feet may provide warmth but does not address the impaired circulation caused by tight restraints. Cool, pale extremities and delayed capillary refill indicate compromised blood flow, requiring immediate restraint adjustment, making this choice less urgent.

Choice B reason: A complete head-to-toe assessment is thorough but delays addressing the critical circulatory compromise indicated by cyanotic nail beds and prolonged capillary refill. Loosening restraints is the priority to restore blood flow, making this choice secondary.

Choice C reason: Loosening the restraints is the first action, as tight restraints likely cause impaired circulation, evidenced by cool, pale extremities, cyanosis, and capillary refill >5 seconds. Restoring blood flow prevents tissue damage, making this the priority intervention for patient safety.

Choice D reason: Assessing blood pressure and respiratory rate is important but not the first action. The localized circulatory issue from restraints requires immediate correction to prevent ischemia, making this choice less urgent than loosening the restraints.

A. Urgent B. Major C. Emergency D. Elective

Correct Answer is C

Explanation

Choice A reason: Urgent procedures are needed soon (e.g., within hours), like appendicitis, but not immediately. Hemorrhaging requires instant action to prevent life-threatening blood loss, making this classification less appropriate than emergency.

Choice B reason: Major refers to procedure complexity, not timing. Hemorrhaging demands immediate intervention regardless of complexity, as bleeding threatens life, making major an incorrect classification for the procedure’s urgency.

Choice C reason: Emergency procedures are required immediately to save life, as with active hemorrhaging. Rapid blood loss risks hypovolemic shock, necessitating urgent surgical return, correctly classifying this as an emergency procedure.

Choice D reason: Elective procedures are planned and non-urgent, like cosmetic surgery. Hemorrhaging is life-threatening, requiring immediate intervention, not a scheduled event, making elective an incorrect classification.

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Order: Diazepam 4 mg via nasogastric tube three times daily. Available: Diazepam oral solution 5 mg per 5 mL. How many milliliters should the client receive per dosage?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a patient in ankle restraints and finds the extremities are cool and pale, nail beds are cyanotic, and capillary refill is >5 seconds. Which action should the nurse take first?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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