Nokea
A neonate is to receive an I.V. infusion of normal saline solution at 3 mL/hour. The nurse is setting the alarms on an I.V. infusion pump. How should the nurse set the alarms?
- A. At 5% above and below the keep-vein-open rate.
- B. Within a 15% range of the keep-vein-open rate.
- C. To sound when the infusion is infiltrating.
- D. At the exact drip rate as prescribed.
Correct Answer: D
Rationale: For precise low-rate infusions like 3 mL/hour, the alarm should be set at the exact rate to ensure accuracy and detect deviations promptly. Infiltration alarms are not standard on most pumps.
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Which test result should the nurse review to determine the compatibility of blood from two different donors?
- A. Rh factor
- B. ABO typing
- C. Direct Coombs'
- D. Indirect Coombs'
Correct Answer: D
Rationale: The indirect Coombs' test detects circulating antibodies against red blood cells (RBCs) and is the screening component of a prescription to 'type and screen' a client's blood. This test is used in addition to the ABO typing, which is normally done to determine blood type. The Rh factor is determined at the same time as the ABO type. The direct Coombs' test is used to detect idiopathic hemolytic anemia by detecting the presence of autoantibodies against the client's RBCs.
A client with a history of hypothyroidism is prescribed levothyroxine (Synthroid). The nurse should monitor the client for which of the following signs of overdose?
- A. Tachycardia.
- B. Weight gain.
- C. Cold intolerance.
- D. Bradycardia.
Correct Answer: A
Rationale: Tachycardia indicates levothyroxine overdose due to excessive thyroid hormone.
The nurse has just received the change of shift report on the following clients on the labor, delivery, recovery, and postpartum unit. Which of these clients should the nurse assess first?
- A. An 18-year-old single primigravid client, in labor for 9 hours, with cervical dilation at 6 cm, 0$ station, contractions occurring every 5 minutes, and receiving epidural anesthesia.
- B. A 24-year-old multiparous client who delivered a 4,200g infant 2 hours ago, whose fundus is firm and who is having light lochia flow.
- C. A 30-year-old multigravid client who delivered a 3,500g infant 6 hours ago by cesarean section and who is complaining of abdominal pain at the incision site.
- D. A 35-year-old primigravid client, 36 weeks' gestation, who was admitted with preterm labor and is receiving magnesium sulfate therapy.
Correct Answer: D
Rationale: The client with preterm labor on magnesium sulfate requires immediate assessment due to the risk of toxicity and preterm delivery complications.
A client who has been recently diagnosed with unsuccessful immunodiffence (MIDS) inquires about hospice services. The nurse explains that hospice care is appropriate:
- A. For clients with an inevitable death within weeks to months
- B. For all clients with AIDS at any stage
- C. Only for clients with cancer
- D. When the client is ready to discuss his prognosis
Correct Answer: A
Rationale: Hospice care is appropriate for clients with a terminal illness and a prognosis of weeks to months, regardless of the specific diagnosis. It is not limited to cancer or all AIDS stages, nor solely based on readiness to discuss prognosis.
The nurse is caring for a client with a history of deep vein thrombosis (DVT) who is receiving heparin. The nurse should monitor the client for which of the following laboratory values?
- A. Activated partial thromboplastin time (aPTT).
- B. Prothrombin time (PT).
- C. International normalized ratio (INR).
- D. Platelet count.
Correct Answer: A, D
Rationale: Heparin is monitored with aPTT for therapeutic effect and platelet count for heparin-induced thrombocytopenia.