Nokea
A nurse is preparing to administer lactated Ringer's (LR) IV 100 mL over 15 minutes. The nurse should set the infusion pump to deliver how many mL/hr?
Correct Answer: 400
Rationale: The correct answer is 400 mL/hr. To calculate the mL/hr rate, we first convert the 15 minutes to hours (15 minutes ÷ 60 minutes = 0.25 hours). Then, we divide the total volume (100 mL) by the time in hours (100 mL ÷ 0.25 hours = 400 mL/hr). This rate ensures the safe and accurate administration of 100 mL of LR over a 15-minute period. Other choices are incorrect because they do not accurately calculate the mL/hr rate based on the given parameters.
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A nurse educator is reviewing with a newly hired nurse the difference in clinical manifestations of a localized vs. a systemic infection. The nurse indicates understanding when she states that which of the following are clinical manifestations of a systemic infection? Select all.
- A. Fever
- B. Malaise
- C. Edema
- D. Pain or tenderness
- E. Increase in pulse & respiratory rate
Correct Answer: A, B, E
Rationale: The correct answer is A, B, E. Fever is a common systemic response to infection as the body raises its temperature to help fight off pathogens. Malaise, a general feeling of discomfort or uneasiness, is also a systemic manifestation indicating a more widespread infection affecting overall well-being. An increase in pulse and respiratory rate can indicate systemic involvement as the body tries to cope with the infection. Edema, pain, or tenderness are more indicative of localized infections and not typically seen in systemic infections.
A client is about to undergo an elective surgical procedure. Which of the following actions are appropriate for the nurse who is providing preop care regarding informed consent? Select all.
- A. Make sure the surgeon obtained the client's consent
- B. Witness the client's signature on the consent form
- C. Explain the risks and benefits of the procedure
- D. Describe the consequences of choosing not to have the surgery
- E. Tell the client about alternatives to having the surgery
Correct Answer: A, B
Rationale: Correct Answer: A, B
Rationale:
A: The nurse should ensure the surgeon obtained the client's consent as the surgeon is responsible for informing the client about the procedure and obtaining consent.
B: Witnessing the client's signature on the consent form ensures that the client signed voluntarily and with full understanding.
Summary:
C: While explaining risks and benefits is important, it is primarily the surgeon's responsibility.
D: Describing consequences of not having surgery is relevant but not directly related to obtaining informed consent.
E: Although discussing alternatives is crucial, it is not a direct part of the informed consent process.
A provider is discharging a client with a prescription for home oxygen therapy via nasal cannula. Client & family teaching by the nurse should include which of the following? Select all.
- A. Apply petroleum jelly around the inside of the nares
- B. Remove the nasal cannula during mealtimes
- C. Check the position of the cannula often
- D. Report any nasal stuffiness, nausea, or fatigue
- E. Post 'no smoking' signs in a prominent location
Correct Answer: C, D, E
Rationale: The correct answers are C, D, and E.
C: Checking the position of the cannula often ensures proper oxygen delivery and prevents skin breakdown.
D: Reporting nasal stuffiness, nausea, or fatigue is crucial as they may indicate oxygen therapy-related complications.
E: Posting 'no smoking' signs is essential as oxygen is flammable and smoking near oxygen can lead to fires.
A: Applying petroleum jelly can interfere with oxygen delivery and increase the risk of skin breakdown.
B: Removing the nasal cannula during mealtimes can decrease oxygen levels, especially in clients requiring continuous therapy.
A nurse is reviewing the reported medications of a client who was recently admitted. The medications include cimetidine (Tagamet) and imipramine hydrochloride (Tofranil). Knowing that cimetidine decreases the metabolism of imipramine hydrochloride, the nurse should identify that this combination is likely to result in which of the following effects?
- A. Decreased therapeutic effects of cimetidine
- B. Increased risk of imipramine hydrochloride toxicity
- C. Decreased risk of adverse effects of cimetidine
- D. Increased therapeutic effects of imipramine hydrochloride
Correct Answer: B
Rationale: The correct answer is B: Increased risk of imipramine hydrochloride toxicity. Cimetidine inhibits the metabolism of imipramine hydrochloride, leading to increased levels of imipramine in the body. This can result in a higher concentration of imipramine, potentially causing toxicity. This interaction is known as a pharmacokinetic drug-drug interaction.
Incorrect choices:
A: Decreased therapeutic effects of cimetidine - This is incorrect because cimetidine's therapeutic effects are not directly impacted by its interaction with imipramine.
C: Decreased risk of adverse effects of cimetidine - This is incorrect as there is no evidence to suggest that the interaction with imipramine decreases the risk of adverse effects of cimetidine.
D: Increased therapeutic effects of imipramine hydrochloride - This is incorrect as the increased risk of toxicity does not equate to increased therapeutic effects.
A nurse who is admitting a client who has a fractured femur obtains a blood pressure reading of 140/94 mmHg. The client denies any history of hypertension. Which of the following actions should the nurse take next?
- A. Request a prescription for an antihypertensive medication
- B. Ask the client if she is having pain
- C. Request a prescription for an anti-anxiety medication
- D. Return in 30 minutes to recheck the client's BP
Correct Answer: B
Rationale: The correct answer is B. When a client with a fractured femur presents with an elevated blood pressure reading, it is important for the nurse to first assess if the client is in pain. Pain can cause an increase in blood pressure due to stress and sympathetic nervous system activation. Addressing pain management is crucial to providing holistic care and may help lower the blood pressure without the need for antihypertensive medications. Requesting an antihypertensive medication (choice A) without addressing the potential pain issue would not be appropriate at this time. Similarly, requesting an anti-anxiety medication (choice C) without further assessment would not address the underlying cause of the elevated blood pressure. Returning in 30 minutes to recheck the client's BP (choice D) is not as proactive as addressing the potential pain issue immediately.