Nokea
A client has orders for a heparin drip with 20,000 units in a 250 mL bag. The heparin must be delivered at 854 units per hour. What rate will the nurse set for the IV?
Correct Answer: 10.7 mL/hr.
Rationale: Concentration: 20,000 units/250 mL = 80 units/mL. Rate: 854 units/hr ÷ 80 units/mL = 10.675 mL/hr, rounded to 10.7 mL/hr.
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The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?
- A. The client with Cushing's disease
- B. The client with diabetes
- C. The client with acromegaly
- D. The client with myxedema
Correct Answer: A
Rationale: Cushing's disease causes immunosuppression, increasing infection risk, warranting a private room.
A client has a diagnosis of discoid lupus erythematosus (DLE). The nurse recognizes that discoid lupus differs from systemic lupus erythematosus because it:
- A. Produces changes in the kidneys
- B. Is confined to changes in the skin
- C. Results in damage to the heart and lungs
- D. Affects both joints and muscles
Correct Answer: B
Rationale: Discoid lupus erythematosus primarily affects the skin, causing chronic rashes, unlike systemic lupus, which can involve multiple organs.
A vaginal exam reveals a breech presentation in a newly admitted client. The nurse should take which of the following actions at this time?
- A. Prepare the client for a caesarean section
- B. Apply the fetal heart monitor
- C. Place the client in the Trendelenburg position
- D. Perform an ultrasound exam
Correct Answer: B
Rationale: Applying the fetal heart monitor assesses fetal well-being in a breech presentation, guiding further management.
The emergency room is flooded with clients injured in a tornado. Which clients can be assigned to share a room in the emergency department during the disaster?
- A. A schizophrenic client having visual and auditory hallucinations and the client with ulcerative colitis
- B. The client who is six months pregnant with abdominal pain and the client with facial lacerations and a broken arm
- C. A child whose pupils are fixed and dilated and his parents, and a client with a frontal head injury
- D. The client who arrives with a large puncture wound to the abdomen and the client with chest pain
Correct Answer: B
Rationale: The pregnant client and the client with facial lacerations/broken arm have stable conditions suitable for sharing a room, unlike the other pairs with critical or incompatible needs.
The nurse is providing dietary instructions for a client with iron-deficiency anemia. Which food is a poor source of iron?
- A. Tomatoes
- B. Legumes
- C. Dried fruits
- D. Nuts
Correct Answer: A
Rationale: Tomatoes are a poor source of iron compared to legumes, dried fruits, and nuts, which are rich in iron and recommended for iron-deficiency anemia.