Nokea
A client receives a prescription for 3 liters of lactated Ringer's IV to infuse over 24 hours. How many mL/hr should the nurse program the infusion pump?
- A. 125
Correct Answer: A
Rationale: To calculate: 3000 mL / 24 hr = 125 mL/hr. The nurse should program the infusion pump to deliver 125 mL/hr.
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A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important for the nurse to report which assessment finding to the healthcare provider?
- A. Muscle atrophy.
- B. Low grade fever.
- C. Joint pain.
- D. Hematuria.
Correct Answer: D
Rationale: Hematuria can indicate lupus nephritis, a serious complication of SLE. Prompt reporting to the healthcare provider is crucial for appropriate management and prevention of further kidney damage.
A client arrives to the medical-surgical unit 4 hours after a transurethral resection of the prostate (TURP). A triple-lumen catheter for continuous bladder irrigation with 0.9% sodium chloride is infusing and the nurse observes dark, pink-tinged outflow with blood clots in the tubing and collection bag. Which action should the nurse take?
- A. Discontinue infusing solution.
- B. Irrigate the catheter manually.
- C. Monitor catheter drainage.
- D. Decrease the flow rate.
Correct Answer: C
Rationale: Monitoring catheter drainage allows the nurse to assess the effectiveness of bladder irrigation and the presence of clot formation, ensuring adequate drainage.
Which dietary instruction is most important for the nurse to explain to a client who has had gastric bypass surgery?
- A. Sip fluids with each meal.
- B. Chew slowly and thoroughly.
- C. Reduce intake of fatty foods.
- D. Eat small frequent meals.
Correct Answer: D
Rationale: Eating small frequent meals is crucial after gastric bypass surgery to prevent complications like dumping syndrome and manage portion sizes effectively.
The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observes vital signs of a heart rate of 140 beats/minute, a respiratory rate of 26 breaths/minute, and a blood pressure of 140/90 mm Hg. Which intervention is most important for the nurse to implement?
- A. Administer IV fluid bolus as prescribed by the healthcare provider.
- B. Medicate for pain and monitor vital signs according to protocol.
- C. Encourage the client to splint the incision with a pillow to cough and deep breathe.
- D. Apply oxygen at 10 L/minute via non-rebreather mask and monitor pulse oximeter.
Correct Answer: B
Rationale: Medicating for pain and monitoring vital signs is the most important intervention, as the elevated vital signs are likely due to inadequate pain control following a thoracotomy, which can lead to increased sympathetic activity.
After falling down the basement steps, a client is brought to the emergency department. X-ray results confirm that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?
- A. Right foot pale with sluggish capillary refill.
- B. Circumferential edema of right foot.
- C. Reports throbbing right leg pain.
- D. Increased temperature to lower extremity.
Correct Answer: A
Rationale: A pale right foot with sluggish capillary refill suggests compromised circulation, possibly due to compartment syndrome, requiring immediate intervention to prevent tissue damage.