Nokea
The healthcare provider orders an IV solution of dextrose 5% in water at 100ml/hour. What would the flow rate be if the drop factor is 15 gtt = 1 ml?
- A. 5 gtt/minute
- B. 13 gtt/minute
- C. 25 gtt/minute
- D. 50 gtt/minute
Correct Answer: C
Rationale: To determine the flow rate in drops per minute, multiply the ordered volume per hour by the drop factor (100 ml/hour x 15 gtt/ml = 1500 gtt/hour). Then, divide the result by 60 minutes to convert it to drops per minute (1500 gtt/hour · 60 minutes = 25 gtt/minute). Therefore, the correct answer is 25 gtt/minute.
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A patient is kept off food and fluids for 10 hours before surgery. His oral temperature at 8 a.m. is 99.8°F (37.7°C). This temperature reading probably indicates:
- A. Infection
- B. Hypothermia
- C. Anxiety
- D. Dehydration
Correct Answer: D
Rationale: A patient being kept off food and fluids before surgery can lead to dehydration. Dehydration can cause a slight increase in body temperature, which could explain the elevated oral temperature reading of 99.8°F (37.7°C) in this scenario. Infections are more likely to cause higher fevers, hypothermia would present with a lower temperature, and anxiety typically does not directly affect body temperature in this manner.
Which action would break sterile technique while preparing a sterile field for a dressing change?
- A. Using sterile forceps instead of sterile gloves to handle a sterile item
- B. Touching the outside wrapper of sterilized material without sterile gloves
- C. Placing a sterile object at the edge of the sterile field
- D. Pouring out a small amount of solution (15 to 30 ml) before pouring it into a sterile container
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which of the following parameters should be checked when assessing respirations?
- A. Rate
- B. Rhythm
- C. Symmetry
- D. All of the above
Correct Answer: D
Rationale: When assessing respirations, it is essential to evaluate the rate at which breaths are taken, the rhythm of breathing patterns, and the symmetry of chest expansion. Each of these parameters provides valuable information about a person's respiratory status. Therefore, it is important to assess all of the listed parameters to have a comprehensive understanding of the individual's respiratory function.
What is the correct sequence for assessing the abdomen?
- A. Tympanic percussion, measurement of abdominal girth, and inspection
- B. Assessment for distention, tenderness, and discoloration around the umbilicus
- C. Percussion, palpation, and auscultation
- D. Auscultation, percussion, and palpation
Correct Answer: D
Rationale: The correct sequence for assessing the abdomen is auscultation, percussion, and palpation. Auscultation allows the healthcare provider to listen for bowel sounds, followed by percussion to assess for areas of tenderness or abnormal distention, and finally palpation to feel for masses or organ enlargement. This sequence ensures a systematic and thorough assessment of the abdomen.
When a family of an accident victim, who has been declared brain-dead, appears open to organ donation, what should the nurse do?
- A. Discourage them from deciding until their grief has eased
- B. Listen to their concerns and answer their questions truthfully
- C. Urge them to immediately sign the consent form
- D. Inform them that the body will not be available for a wake or funeral
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.