Nokea
A healthcare professional is preparing to administer lactated Ringer's (LR) IV 100 mL over 15 min. How many mL/hr should the IV infusion pump be set to deliver? (Round the answer to the nearest whole number. Do not use a trailing zero.)
- A. 400 mL/hr
- B. 200 mL/hr
- C. 300 mL/hr
- D. 250 mL/hr
Correct Answer: A
Rationale: To administer 100 mL over 15 min, the IV pump should be set to deliver 400 mL/hr. This calculation is based on the concept that if 100 mL is given in 15 minutes, to find out how many milliliters are given in an hour, you would multiply by 4 (since 15 minutes is a quarter of an hour). Therefore, 100 mL x 4 = 400 mL per hour. Choices B, C, and D are incorrect as they do not reflect the correct calculation for the infusion rate required to administer 100 mL over 15 minutes.
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A nurse is caring for an older adult client who becomes agitated when the nurse requests the client's dentures be removed prior to surgery. Which of the following responses should the nurse make?
- A. You seem worried. Are you concerned someone may see you without your teeth?
- B. Don't worry, it's just for the surgery.
- C. You need to follow the instructions.
- D. The dentures need to be removed for a reason.
Correct Answer: D
Rationale: The correct response is to provide a clear rationale for the request, as stated in option D. By explaining the purpose behind removing the dentures, the nurse helps the client understand the necessity, which can reduce agitation and promote cooperation. Option A demonstrates empathy by addressing the client's potential concern about being seen without dentures but lacks a direct explanation. Option B dismisses the client's feelings with a casual statement that may not address the underlying issue. Option C is authoritarian and lacks empathy, potentially escalating the client's agitation.
While documenting in a client's medical record, which of the following entries should the nurse record?
- A. "Incision without redness or drainage"
- B. "Drank adequate amounts of fluid with meals"
- C. "Administered pain medication"
- D. "Oral temperature slightly elevated at 0800"
Correct Answer: D
Rationale: The correct answer is D because documenting specific observations, such as an oral temperature being slightly elevated at a specific time, is crucial for monitoring the client's health status accurately. This type of information helps in assessing trends and changes in the client's condition over time. Choice A is incorrect as it lacks specificity and does not provide measurable data about the client's condition. Choice B is incorrect because it is a general statement related to client behavior rather than a specific health observation. Choice C is incorrect as it reflects an action taken by the nurse and not a direct client's condition or observation.
When teaching a client and their family how to care for the client's tracheostomy at home, which of the following should the nurse include?
- A. Use tracheostomy covers when outdoors
- B. Maintain a sterile technique when performing tracheostomy care
- C. Do not remove the outer cannula for routine cleaning
- D. Clean around the stoma with normal saline solution
Correct Answer: A
Rationale: The correct answer is to use tracheostomy covers when outdoors. This practice helps protect the stoma from foreign particles and temperature changes, reducing the risk of infection. Maintaining a sterile technique when performing tracheostomy care (choice B) is important to prevent infections but is not specific to outdoor care. Removing the outer cannula for routine cleaning (choice C) is not recommended as it may cause trauma or dislodgment of the tracheostomy tube. Cleaning around the stoma with povidone-iodine (choice D) is not advisable as it can be irritating to the skin and may impair the healing process.
The nurse is preparing to administer digoxin (Lanoxin) to a client with heart failure. Which assessment finding would prompt the nurse to withhold the medication and contact the healthcare provider?
- A. Heart rate of 55 beats per minute
- B. Blood pressure of 140/90 mmHg
- C. Respiratory rate of 20 breaths per minute
- D. Blood glucose level of 150 mg/dL
Correct Answer: A
Rationale: A heart rate below 60 beats per minute is a contraindication for administering digoxin, as it can lead to bradycardia. Bradycardia is a common adverse effect associated with digoxin toxicity. Blood pressure of 140/90 mmHg, respiratory rate of 20 breaths per minute, and blood glucose level of 150 mg/dL are within normal limits and would not warrant withholding the medication or contacting the healthcare provider in this context. Therefore, a heart rate of 55 beats per minute would prompt the nurse to withhold digoxin and notify the healthcare provider.
Which toy is most appropriate for an 18-month-old child?
- A. A pull toy
- B. A puzzle with large pieces
- C. A book with large pictures
- D. A doll with small clothes
Correct Answer: A
Rationale: A pull toy is the most appropriate choice for an 18-month-old child. At this age, children are developing their motor skills and coordination, and a pull toy can help with these aspects by encouraging movement and coordination. Puzzle with large pieces (Choice B) may pose a choking hazard for a child of this age due to small parts. While a book with large pictures (Choice C) can be engaging and beneficial for language development, a pull toy is more suitable for promoting physical development in an 18-month-old. A doll with small clothes (Choice D) is not ideal for this age group as small parts can be a choking hazard.