Nokea
A client who is recovering from gastric surgery is receiving I.V. fluids to be infused at 100 mL/hour. The I.V. tubing delivers 15 gtt/mL. The nurse should infuse the solution at a flow rate of how many drops per minute to ensure that the client receives 100 mL/hour?
Correct Answer: 25 gtt/minute
Rationale: To calculate: (100 mL/hour × 15 gtt/mL) ÷ 60 minutes/hour = 25 gtt/minute. The nurse should set the flow rate to 25 drops per minute.
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Which of the following dietary measures would be useful in preventing esophageal reflux?
- A. Eating small, frequent meals.
- B. Increasing fluid intake.
- C. Avoiding air swallowing with meals.
- D. Adding a bedtime snack to the dietary plan.
Correct Answer: A
Rationale: Small, frequent meals reduce gastric distention and lower the risk of reflux compared to large meals. The other options are less effective or may worsen symptoms.
After an intravenous pyelogram (IVP), the nurse should not include incorporating which of the following measures into the client's plan of care?
- A. Maintaining bed rest.
- B. Encouraging adequate fluid intake.
- C. Assessing for hematuria.
- D. Administering a laxative.
Correct Answer: D
Rationale: Administering a laxative is unnecessary post-IVP, as it does not aid recovery or contrast excretion, unlike fluid intake or hematuria assessment.
What is a priority nursing intervention for a client with renal colic?
- A. Encourage fluid intake.
- B. Administer morphine as prescribed.
- C. Apply warm compresses.
- D. Insert a urinary catheter.
Correct Answer: B
Rationale: Morphine effectively manages severe renal colic pain, prioritizing client comfort.
A client is to receive epoetin (Epogen) injections. What laboratory value should the nurse assess before giving the injection?
- A. Hematocrit.
- B. Partial thromboplastin time.
- C. Hemoglobin concentration.
- D. Prothrombin time.
Correct Answer: A
Rationale: Epoetin (Epogen) stimulates red blood cell production and is used to treat anemia. The nurse should assess hematocrit before administration to evaluate the client's response to therapy and ensure levels do not rise excessively, which can increase the risk of hypertension or thrombosis. Hemoglobin is also relevant but hematocrit is more commonly monitored. Coagulation times are not directly affected by epoetin.
The nurse is assisting with a bone marrow aspiration and biopsy. In which order, from first to last, should the nurse complete the following tasks?
- A. Verify the client has signed an informed consent.
- B. Position the client in a side-lying position.
- C. Clean the skin with an antiseptic solution.
- D. Apply ice to the biopsy site.
Correct Answer: C,A,B,D
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