Nokea
A client is receiving an IV heparin drip at 16 mL/hr via an infusion pump for a diagnosis of deep vein thrombosis. The label on the 1/2 liter bag of D5W indicates 25,000 units of heparin have been added. How many units of heparin is the client receiving per hour? (Calculate to the nearest whole.)
- A. 800
- B. NA
- C. NA
- D. NA
Correct Answer: A
Rationale: Calculation: 25,000 units ÷ 500 mL × 16 mL = 800 units.
You may also like to solve these questions
A neonate is in the active alert behavioral state. Which of the following would the nurse expect to see?
- A. Baby is showing signs of hunger and frustration.
- B. Baby is starting to whimper and cry.
- C. Baby is wide awake and attending to a picture.
- D. Baby is asleep and breathing rhythmically.
Correct Answer: C
Rationale: Active alert state is characterized by wakefulness and attentiveness.
The nurse is about to elicit the Moro reflex. Which of the following responses should the nurse expect to see?
- A. When the cheek of the baby is touched
- B. the newborn turns toward the side that is touched.
- C. When the lateral aspect of the sole of the baby's foot is stroked
- D. the toes extend and fan outward.
Correct Answer: C
Rationale: Moro reflex involves extension of arms and flexion of knees in response to a sudden stimulus.
Which clinical finding should the nurse suspect if the fundus is palpated on the right side of the abdomen above the expected level?
- A. Distended bladder
- B. Normal involution
- C. Been lying on her right side too long
- D. Stretched ligaments that are unable to support the uterus
Correct Answer: A
Rationale: The correct answer is A, a distended bladder. When the fundus is palpated on the right side above the expected level, it indicates that the bladder is full and pushing the uterus upward and to the right. This can interfere with the normal descent of the uterus during involution, leading to the fundus being higher than expected.
Choice B, normal involution, is incorrect as it does not explain the fundus being palpated above the expected level.
Choice C, lying on her right side too long, is incorrect as body position does not typically result in the fundus being displaced.
Choice D, stretched ligaments that are unable to support the uterus, is incorrect as stretched ligaments would not cause the fundus to be palpated above the expected level; rather, it would lead to a lower position of the uterus.
A woman who wishes to breastfeed advises the nurse that she has had breast augmentation surgery. Which of the following responses by the nurse is appropriate?
- A. Breast implants often contaminate the milk with toxins.
- B. The glandular tissue of women who need implants is often deficient.
- C. Babies often have difficulty latching to the nipples of women with breast implants.
- D. Women who have implants are often able exclusively to breastfeed.
Correct Answer: D
Rationale: Implants do not preclude breastfeeding.
The nurse recognizes the postpartum person is in what stage of Rubin’s attachment model when the person is concerned with physical recovery and depends on the nurse or partner for help physically?
- A. Taking In
- B. Taking Hold
- C. Postpartum Maternal Change
- D. Attainment of Change
Correct Answer: A
Rationale: The correct answer is A: Taking In. In Rubin's attachment model, this stage occurs immediately after childbirth when the person focuses on their own physical recovery and relies on others for assistance. This stage is characterized by passivity and dependence. The other choices are incorrect because: B) Taking Hold is the stage where the person starts to take on more responsibility for themselves and the baby; C) Postpartum Maternal Change is not a recognized stage in Rubin's model; D) Attainment of Change is not a stage in Rubin's model either.