Nokea
A client's IV fluid orders for 24 hour's are 1500 ml D5W followed by 1250 ml of NS. The IV tubing has a drop factor of 15 gtt/ml. To administer the required fluids the nurse should set the drip rate at;
- A. 13 gtt/min
- B. 29 gtt/min
- C. 16 gtt/min
- D. 32 gtt/min Situation 5: Protection of self and patient can be done by supporting the body's immunity.
Correct Answer: B
Rationale: To calculate the drip rate, we first need to find the total volume of IV fluid to be administered, which is 1500 ml + 1250 ml = 2750 ml. Then, we multiply the total volume by the drop factor (2750 ml * 15 gtt/ml = 41250 gtt). Finally, we divide the total number of drops by the time in minutes (24 hours * 60 min = 1440 min) to get the drip rate: 41250 gtt / 1440 min = 28.47 gtt/min, which rounds up to 29 gtt/min. Therefore, choice B is correct. Choices A, C, and D are incorrect because they do not reflect the accurate calculation based on the given parameters.
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Considering Mr. Franco’s conditions, which of the following is most important to include in preparing Franco’s bedside equipment?
- A. Hand bell and extra bed linen
- B. Footboard and splint
- C. Sandbag and trochanter rolls
- D. Suction machine and gloves
Correct Answer: B
Rationale: Step-by-step rationale for choice B: Footboard and splint:
1. Footboard helps prevent foot drop by maintaining proper alignment and preventing pressure ulcers.
2. Splint helps stabilize and support Franco's limbs to prevent contractures and maintain proper positioning.
3. Both items are essential for Franco's safety, comfort, and prevention of complications.
4. Hand bell and extra bed linen (Choice A) are not crucial for Franco's immediate care needs.
5. Sandbag and trochanter rolls (Choice C) are not directly relevant to Franco's specific conditions.
6. Suction machine and gloves (Choice D) are important for airway management but not the priority for bedside equipment in this case.
Which of the ff nursing interventions is essential for a client during the Schilling test?
- A. Collecting urine 24-48 hrs after the client has received nonradioactive B12
- B. Collecting blood samples of 50 ml for 24-48 hrs after the client has received the nonradioactive B12
- C. Not allowing any oral fluid consumption for 24-48 hrs after the client has received nonradioactive B12
- D. Making the client lie down in the supine position for 24-48 hrs after the client has received nonradioactive B12 CARING FOR CLIENTS WITH DISORDERS OF THE HEMATOPOIETIC SYSTEM
Correct Answer: A
Rationale: The correct answer is A because collecting urine 24-48 hrs after the client has received nonradioactive B12 is essential for the Schilling test to evaluate vitamin B12 absorption. Urine is collected to measure the excretion of radioactive B12, which helps in diagnosing pernicious anemia or malabsorption issues.
Incorrect choices:
B: Collecting blood samples is not necessary for the Schilling test as it primarily involves urine collection.
C: Allowing oral fluid consumption is important to prevent dehydration and is not contraindicated after receiving nonradioactive B12.
D: Making the client lie down in the supine position is unnecessary for the Schilling test and may not affect the test results.
The nurse is caring for a patient with HIV who has diarrhea. Which of the following would be most therapeutic to teach the patient to avoid in the diet to reduce diarrhea?
- A. Potassium-rich food
- B. Liquid nutritional supplements
- C. Raw fruits and vegetables
- D. Frozen products
Correct Answer: C
Rationale: The correct answer is C: Raw fruits and vegetables. Patients with HIV and diarrhea should avoid raw fruits and vegetables due to their high fiber content, which can exacerbate diarrhea symptoms. Fiber can increase bowel movements and worsen diarrhea. Therefore, avoiding raw fruits and vegetables can help reduce diarrhea.
Choice A (Potassium-rich food) is not the best answer because potassium-rich foods are important for patients with HIV to maintain electrolyte balance. Choice B (Liquid nutritional supplements) can actually be beneficial in providing essential nutrients to patients with HIV. Choice D (Frozen products) is not directly related to diarrhea management in patients with HIV.
. A female client experiences trauma to her urinary tract during an accident. Which of the ff factors should the nurse consider while assessing the client?
- A. Assessment of sexual habits
- B. Assessment and recognition of abnormal findings
- C. Assessment of allergies to seafood
- D. Assessment of insurance coverage
Correct Answer: B
Rationale: The correct answer is B: Assessment and recognition of abnormal findings. This is crucial as trauma to the urinary tract can lead to various complications such as urinary retention, infection, or injury to surrounding structures. By assessing and recognizing abnormal findings, the nurse can promptly identify any issues and initiate appropriate interventions.
Choice A (Assessment of sexual habits) may be important for assessing risk factors for urinary tract trauma, but it is not directly related to assessing the client's current condition post-accident. Choice C (Assessment of allergies to seafood) is irrelevant in this scenario as it does not impact the assessment of urinary tract trauma. Choice D (Assessment of insurance coverage) is not a priority when assessing a client's immediate health status post-accident.
A complete blood count is commonly performed before a client goes into surgery. What does this test seek to identify?
- A. Potential hepatic dysfunction indicated by decreased blood urea nitrogen (BUN) and creatinine levels
- B. Low levels of urine constituents normally excreted in the urine
- C. Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels
- D. Electrolyte imbalance that could affect the blood’s ability to coagulate properly
Correct Answer: C
Rationale: Rationale for Correct Answer (C): A complete blood count (CBC) is used to identify abnormalities in red blood cells, white blood cells, and platelets. Hematocrit (HCT) and hemoglobin (Hb) levels are part of a CBC and indicate the oxygen-carrying capacity of the blood. Abnormally low HCT and Hb levels can signify conditions like anemia, which can impact a client's ability to undergo surgery due to potential complications related to oxygen delivery.
Summary of Incorrect Choices:
A: Potential hepatic dysfunction is not directly related to a CBC, and BUN/creatinine levels are markers for kidney function, not liver function.
B: Low levels of urine constituents are not assessed in a CBC, which focuses on blood components.
D: Electrolyte imbalance is not specifically tested in a CBC; it is usually evaluated through separate blood tests. Coagulation factors are not directly measured in a CBC.