Nokea
A 50-milliliter (ml) bolus of normal saline fluid is ordered by the physician. The physician wants it to infuse in 30 minutes. The nurse should set the pump rate at:
- A. 100 ml per hour for one hour.
- B. 60 ml per hour for one-half hour
- C. 120 ml per hour for one hour.
- D. 50 ml per hour for one hour.
Correct Answer: A
Rationale: To infuse a 50 ml bolus in 30 minutes, the rate should be calculated as follows: 50 ml / 30 min = 100 ml per hour. Therefore, the correct answer is to set the pump rate at 100 ml per hour for one hour. Choice A is the correct rate based on the calculation. Choices B, C, and D all provide incorrect rates that do not match the physician's order. Choice B would only deliver 30 ml in 30 minutes, not the ordered 50 ml. Choice C would deliver 120 ml in one hour, which is 20 ml more than ordered. Choice D would only provide 25 ml over 30 minutes, not the full 50 ml prescribed.
You may also like to solve these questions
The mother of a newborn child is very upset. The child has a cleft lip and palate. The type of crisis this mother is experiencing is:
- A. reactive.
- B. maturational.
- C. situational.
- D. adventitious.
Correct Answer: C
Rationale: The mother is experiencing a situational crisis as the unexpected birth of a child with a cleft lip and palate has placed her in a challenging situation she did not anticipate. This type of crisis is triggered by specific events and circumstances. Choice A, reactive, implies responding to a stressor after it has occurred, which is not the case here. Choice B, maturational, refers to stress related to developmental stages, not to external events like the child's condition. Choice D, adventitious, involves crises resulting from events outside one's control, such as natural disasters, which do not apply in this scenario.
The ethical principle of keeping professional promises or obligations is:
- A. veracity
- B. autonomy
- C. fidelity
- D. beneficence
Correct Answer: C
Rationale: The correct answer is fidelity. Fidelity is the ethical principle that refers to keeping professional promises or obligations. Veracity, however, relates to truth-telling. Autonomy is about client self-determination and decision-making. Beneficence, on the other hand, involves doing good and is crucial in the provision of nursing care.
A man expresses surprise that his wife has become very withdrawn during hospitalization for pneumonia. Which response helps the husband understand how some people cope with hospitalization?
- A. "Hospitalization might cause a crisis. Has your wife had to cope with problems before this?"?
- B. "Some people react that way. She will be more talkative when she feels better."?
- C. "Your wife might be feeling concern that she cannot fulfill her normal roles."?
- D. "This is typical behavior for someone who is as ill as your wife."?
Correct Answer: A
Rationale: The correct response acknowledges that hospitalization can lead to a crisis for both patients and their families. By asking if the wife has coped with problems before, it opens up a dialogue about her coping mechanisms and past experiences. This can help the husband understand his wife's current behavior better and provide valuable insights. Choices B, C, and D do not directly address the potential crisis that hospitalization can cause or inquire about the wife's coping strategies, making them less effective responses.
Which of the following clients should refrain from therapy with the thiazide diuretic hydrochlorothiazide?
- A. a client with renal impairment
- B. a client with hypertension
- C. a client with diabetes mellitus, type II
- D. a client with renal calculi (kidney stones)
Correct Answer: C
Rationale: The correct answer is a client with diabetes mellitus, type II. Thiazide diuretics like hydrochlorothiazide can cause metabolic abnormalities, including elevated blood glucose levels. This increase is linked to diuretic-induced potassium deficiency, which reduces insulin secretion, leading to higher plasma glucose levels. Thiazides are commonly used in clients with renal impairment and hypertension. Moreover, thiazides decrease calcium excretion, reducing the risk of renal calculi, so it is not contraindicated for clients with kidney stones. Therefore, clients with diabetes mellitus, type II should avoid therapy with hydrochlorothiazide due to the potential adverse effects on blood glucose levels.
When working with a client diagnosed with Borderline Personality Disorder who frequently attempts self-harm, what is the best intervention to facilitate behavior change?
- A. Constantly observing the client to prevent self-harm.
- B. Enlisting the client in defining and describing harmful behaviors.
- C. Checking on the client every 15 minutes to ensure they are not engaging in harmful behavior.
- D. Removing all items from the environment that the client could use to harm themselves.
Correct Answer: B
Rationale: The most effective intervention when working with clients who have a history of self-harm, like the client diagnosed with Borderline Personality Disorder, is to involve them actively in their treatment. By enlisting the client to define and describe the harmful behaviors, the client becomes an integral part of identifying triggers and understanding the underlying causes of their actions. This approach empowers the client, promotes self-awareness, and fosters a sense of control over their behaviors. Constantly observing the client (Choice A) may lead to a lack of trust and hinder the therapeutic relationship. Checking on the client every 15 minutes (Choice C) may disrupt the client's sense of autonomy and privacy. Removing all items from the environment that could be used for self-harm (Choice D) is a temporary solution and does not address the root causes of the behavior.