Nokea
A client is to receive 1,000 mL of potassium chloride in 5% dextrose injection (D5W) intravenously over 3 hours and 20 minutes using a drop factor of 15 drops/mL. What is the required flow rate (drops) per minute? Record your answer using a whole number.
Correct Answer: 75
Rationale: To calculate the flow rate in drops per minute, use the formula: (Total volume X Drop factor)/ Total time in minutes. The total volume is 1,000 mL, the drop factor is 15 drops/mL, and the time is 3 hours 20 minutes = 200 minutes. Thus, (1,000 X 15)/ 200 = 15,000/ 200 = 75 drops/minute.
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- A. beef stew
- B. hard-boiled egg
- C. custard
- D. sliced peaches
Correct Answer: C
Rationale: Custard is smooth and pureed, suitable for a dysphagia diet. Other options pose choking risks due to texture.
A client with a right lobectomy is being transported from the intensive care unit to a medical unit. The nurse understands that the client's chest drainage system:
- A. Can be disconnected from suction if the chest tube is clamped
- B. Can be disconnected from suction, but the chest tube should remain unclamped
- C. Must remain connected by means of a portable suction
- D. Must be kept even with the client's shoulders during the transport
Correct Answer: B
Rationale: The chest tube should remain unclamped and disconnected from suction during transport to prevent tension pneumothorax, with the system kept below chest level.
The nurse is teaching a client with a new diagnosis of glaucoma about eye drop administration. Which of the following instructions should the nurse include?
- A. Apply pressure to the inner canthus after instilling drops.
- B. Instill the drops directly onto the cornea.
- C. Shake the bottle vigorously before use.
- D. Store the drops in the refrigerator.
Correct Answer: A
Rationale: applying pressure to the inner canthus (nasolacrimal occlusion) prevents systemic absorption of the medication
A homeless client has been admitted to the hospital for observation, and he does not speak any English. The nurse does not know any of the client's medical history, but he is grimacing and looks to be in pain. The nurse should
- A. use nonverbal communication such as pointing and gestures.
- B. call for the hospital interpreter services.
- C. give the client pen and paper and encourage him to draw.
- D. wait to see if any friends or family visit the client who may be able to help.
Correct Answer: B
Rationale: An interpreter ensures accurate communication for assessing pain and history, respecting patient needs and safety.
A client with cancer is admitted to the oncology unit. Stat lab values reveal Hgb 12.6, WBC 6500, K+ 1.9, uric acid 7.0, Na+ 136, and platelets 178,000. The nurse evaluates that the client is experiencing which of the following?
- A. Hypernatremia
- B. Hypokalemia
- C. Myelosuppression
- D. Leukocytosis
Correct Answer: B
Rationale: A potassium level of 1.9 mEq/L indicates hypokalemia, which is a critical electrolyte imbalance.