Nokea
Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5.5 hours. How much heparin has the client received?
- A. 11,000 units.
- B. 13,000 units.
- C. 15,000 units.
- D. 17,000 units.
Correct Answer: A
Rationale: To calculate the total amount of heparin received, multiply the infusion rate (50 ml/hour) by the total infusion time (5.5 hours). This results in 275 ml of the solution infused. Since there are 20,000 units of heparin in 500 ml, there are 800 units per ml. Therefore, 275 ml contains 220,000 units. However, the heparin is diluted in 500 ml, so the client has received half of this amount, which is 110,000 units. Therefore, the correct answer is 11,000 units. Choices B, C, and D are incorrect as they do not reflect the correct calculation based on the provided information.
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A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the LPN/LVN to implement?
- A. Obtain the pre-transfusion hemoglobin level.
- B. Prime the tubing and set up the blood pump.
- C. Monitor vital signs every 15 minutes for the first hour.
- D. Ensure the accuracy of the blood type match.
Correct Answer: D
Rationale: Ensuring the accuracy of the blood type match is crucial to prevent transfusion reactions. The LPN/LVN must prioritize this step to avoid adverse outcomes. Obtaining the pre-transfusion hemoglobin level (Option A) is important but not as critical as ensuring blood type compatibility. Priming the tubing and setting up the blood pump (Option B) and monitoring vital signs every 15 minutes (Option C) are essential steps in the transfusion process, but the primary concern should be preventing transfusion reactions by verifying blood type compatibility.
A health care provider has prescribed isoniazid (Laniazid) for a client. Which instruction should the LPN give the client about this medication?
- A. Prolonged use does not typically cause dark concentrated urine.
- B. It is not necessary to take the medication on an empty stomach for optimal absorption.
- C. Avoid taking the medication with aluminum hydroxide to minimize GI upset.
- D. Drinking alcohol daily can cause drug-induced hepatitis.
Correct Answer: D
Rationale: The correct answer is D. When taking isoniazid, alcohol consumption should be avoided as it can increase the risk of liver damage, potentially leading to drug-induced hepatitis. Choices A, B, and C are incorrect. Prolonged use of isoniazid does not typically cause dark concentrated urine; it is not necessary to take the medication on an empty stomach for optimal absorption; and it is not recommended to take isoniazid with aluminum hydroxide to minimize GI upset.
A client is receiving total parenteral nutrition (TPN). The nurse should monitor the client for which complication?
- A. Hypoglycemia
- B. Hyperglycemia
- C. Hypertension
- D. Hyperkalemia
Correct Answer: B
Rationale: Hyperglycemia is the correct complication to monitor for in a client receiving total parenteral nutrition (TPN) due to the high glucose content of the solution. TPN solutions are rich in glucose, so monitoring blood glucose levels is crucial to prevent hyperglycemia. Hypoglycemia (Choice A) is less common with TPN due to the high glucose content, making hyperglycemia a more significant concern. Hypertension (Choice C) and hyperkalemia (Choice D) are not typically associated with TPN administration, making them incorrect choices in this scenario.
A nurse is preparing an education program for staff about advocacy. What information should the nurse include?
- A. Advocacy ensures clients' safety, health, and rights.
- B. Advocacy involves only supporting client complaints.
- C. Advocacy means making all decisions for the client.
- D. Advocacy is not part of nursing responsibilities.
Correct Answer: A
Rationale: The correct answer is A. Advocacy in nursing involves ensuring clients' safety, health, and rights. Nurses advocate for their clients by promoting autonomy, informed decision-making, and protecting their rights. Choice B is incorrect because advocacy goes beyond just supporting client complaints; it encompasses a broader scope of ensuring holistic care and well-being. Choice C is incorrect as advocacy does not mean making all decisions for the client but rather empowering them to make informed choices. Choice D is incorrect as advocacy is a crucial component of nursing responsibilities, as it involves standing up for clients' best interests and ensuring their rights are respected.
An older adult client just diagnosed with colon cancer asks the nurse what the primary care provider is going to do. The provider will be making rounds within the hour. Which of the following nursing actions is appropriate?
- A. Help the client write down the questions to ask the provider, so that the client doesn't forget
- B. Reassure the client that everything will be explained
- C. Explain the procedure in detail yourself
- D. Direct the client to search for information online
Correct Answer: A
Rationale: Assisting the client in preparing questions is the most appropriate action as it helps ensure that all concerns are addressed during the provider's visit. By helping the client write down questions, the nurse empowers the client to actively participate in their care and communicate effectively with the provider. Reassuring the client, while well-intentioned, may not address the specific questions or fears the client has. Explaining the procedure in detail may not be what the client is seeking at this moment, as their primary concern is about the provider's actions. Directing the client to search for information online is not recommended as it may lead to confusion or misinformation, and the information may not be tailored to the client's specific situation.