Nokea
A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client's intravenous infusion pump?
- A. 13 ml/hour.
- B. 63 ml/hour.
- C. 80 ml/hour.
- D. 125 ml/hour.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A male client is laughing at a television program with his wife when the evening nurse enters the room. He says his foot is hurting and he would like a pain pill. How should the nurse respond?
- A. Ask him to rate his pain on a scale of 1 to 10.
- B. Encourage him to wait until bedtime so the pill can help him sleep.
- C. Attend to an acutely ill client's needs first because this client is laughing.
- D. Instruct him in the use of deep breathing exercises for pain control.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A female UAP is assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented. The UAP requests a change in assignment because she has not yet been fitted for a particulate filter mask. Which action should the nurse take?
- A. Advise the UAP to wear a standard face mask to take vital signs and then get fitted for a filter mask before providing personal care.
- B. Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client.
- C. Instruct the UAP that a standard mask is sufficient for the provision of care for the assigned client.
- D. Before changing assignments, determine which staff members have fitted particulate filter masks.
Correct Answer: C
Rationale: The correct answer is C. For droplet precautions, such as in the case of pertussis, a standard face mask is sufficient for protection. Particulate filter masks are required for airborne precautions, not for droplet precautions. Therefore, the UAP can proceed with taking the vital signs using a standard mask without the need for a particulate filter mask. It is important for healthcare workers to understand the appropriate use of personal protective equipment based on the type of precautions in place to provide safe and effective care to clients.
A staff member is assigned to care for a close friend in the hospital setting. Which action should the staff member take first when given the assignment?
- A. Notify the friend that all medical information will be kept confidential.
- B. Explain the relationship to the charge nurse and ask for reassignment.
- C. Approach the client and ask if the assignment is uncomfortable.
- D. Accept the assignment but protect the client's confidentiality.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which intervention is most important when caring for a client with a chest tube?
- A. Keep the drainage system at chest level.
- B. Ensure that the chest tube is clamped at all times.
- C. Strip the chest tube every shift.
- D. Ensure that the chest tube is connected to a water-seal drainage system.
Correct Answer: D
Rationale: The most crucial intervention when caring for a client with a chest tube is to ensure that the chest tube is connected to a water-seal drainage system (D). This system helps maintain proper lung expansion and prevents complications. Keeping the drainage system at chest level (A) is important to facilitate drainage, but not as critical as ensuring the connection to the drainage system. Clamping the chest tube (B) is unnecessary and can lead to serious issues. Stripping the chest tube (C) is an outdated practice and can cause harm rather than benefit.
The healthcare provider assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the healthcare provider do next?
- A. Apply a warm compress proximal to the site.
- B. Check for kinks in the tubing and raise the IV pole.
- C. Adjust the tape that stabilizes the needle.
- D. Flush with normal saline and recount the drop rate.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.