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A nurse is preparing to administer 0.9% sodium chloride (0.9% NaCl) 250 mL IV to infuse over 30 minutes. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?
Correct Answer: 83
Rationale: To calculate the drip rate, we can use the formula: Drip rate = (Volume to be infused in gtt) / Time in minutes. In this case, the volume to be infused is 250 mL, and the time is 30 minutes. Convert 250 mL to drops: 250 mL x 10 gtt/mL = 2500 gtt. Now, divide 2500 gtt by 30 minutes to get 83.33 gtt/min. Since we can't administer a fraction of a drop, we round down to the nearest whole number, which is 83 gtt/min. This rate ensures the 0.9% NaCl solution is administered accurately over the specified time. Other choices are incorrect because they do not result from the correct calculation based on the given information.
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A nurse is working with a newly hired nurse who is administering meds to clients. Which of the following actions by the newly hired nurse indicates an understanding of med error prevention?
- A. Taking all meds out of the unit-dose wrappers before entering the client's room.
- B. Checking with the provider when a single dose requires administration of multiple tablets.
- C. Administering a med, then looking up the usual dosage range.
- D. Relying on another nurse to clarify a med prescription.
Correct Answer: B
Rationale: Correct Answer: B
Rationale: Choice B demonstrates understanding of med error prevention because checking with the provider when a single dose requires administration of multiple tablets ensures accuracy in medication administration. This step helps prevent medication errors related to dosage calculation and administration. By consulting the provider, the nurse confirms the correct dosage and avoids potential overdosing or underdosing, which are common causes of medication errors. This action aligns with the principles of safe medication administration and prioritizes patient safety.
Incorrect Choices:
A: Taking all meds out of the unit-dose wrappers before entering the client's room can lead to medication mix-ups and errors, as it increases the risk of confusion and misidentification of medications.
C: Administering a med, then looking up the usual dosage range is risky as it may result in incorrect dosing and jeopardize patient safety.
D: Relying on another nurse to clarify a med prescription is problematic as it bypasses the responsibility of verifying medication orders directly with the prescriber
A nurse enters a client's room & finds him sitting in his chair. He states, 'I fell in the shower, but I got myself back up & into my chair.' How should the nurse document this in the client's chart?
- A. The client fell in the shower.
- B. The client states he fell in the shower & was able to get himself back into his chair.
- C. The nurse should not document this info because she did not witness the fall.
- D. The client fell in the shower & is now resting comfortably.
Correct Answer: B
Rationale: Correct Answer: B. The client states he fell in the shower & was able to get himself back into his chair.
Rationale: This answer accurately reflects the client's own account of the events without making any assumptions. It documents both the fall and the client's ability to self-recover, which are essential details for the client's care plan.
Summary of Incorrect Choices:
A: This option only mentions the fall without acknowledging the client's ability to get back up, which is crucial information.
C: It is important to document the client's report even if the nurse did not witness the fall, as it provides valuable insight into the client's condition.
D: This option adds unnecessary information about the client's current state that is not directly related to the fall incident.
A nurse is teaching a client about taking multiple oral meds at home to include time-release capsules, liquid meds, enteric-coated pills, & narcotics. Which of the following statements by the client indicates an understanding of the teaching?
- A. I can open the capsule w/the beads in it & sprinkle them on my oatmeal.
- B. If I am having difficulty swallowing, I will add the liquid meds to a batch of pudding.
- C. The pills w/the coating on them can be crushed.
- D. I will eat 2 crackers w/the pain pills.
Correct Answer: D
Rationale: The correct answer is D: "I will eat 2 crackers with the pain pills." This statement indicates an understanding of the teaching because taking narcotics with food, such as crackers, can help reduce stomach upset and nausea commonly associated with these medications. This demonstrates the client's awareness of the importance of food intake when taking certain medications.
Choice A is incorrect because opening a time-release capsule and sprinkling the beads on food can alter the medication's intended release mechanism. Choice B is incorrect as mixing liquid meds with pudding may not ensure proper dosage or absorption. Choice C is incorrect as crushing enteric-coated pills can interfere with their delayed-release properties.
A nurse is preparing to instill an enteral feeding to a client who has an NG tube in place. What is the nurse's highest assessment priority before performing this procedure?
- A. Check how long the feeding container has been opened.
- B. Verify the placement of the NG tube.
- C. Confirm that the client doesn't have diarrhea.
- D. Make sure the client is alert & oriented.
Correct Answer: B
Rationale: The correct answer is B: Verify the placement of the NG tube. This is the highest assessment priority before instilling enteral feeding to prevent complications like aspiration. The nurse must ensure the NG tube is correctly positioned in the stomach to avoid feeding into the lungs. Checking the length of time the feeding container has been open (A) is important but not as critical as verifying tube placement. Confirming the client doesn't have diarrhea (C) is important for monitoring overall health but not directly related to the procedure. Ensuring the client is alert and oriented (D) is essential but not the priority for this specific procedure.
A nurse on a med-surg unit has received change-of-shift report & will care for 4 clients. Which of the following client's needs may the nurse assign to assistive personnel (AP)?
- A. Feeding a client who was admitted 24 hrs ago w/aspiration pneumonia
- B. Reinforcing teaching w/a client who is learning to walk using a quad cane
- C. Reapplying a condom catheter for a client who has urinary incontinence
- D. Applying a sterile dressing to a pressure ulcer
Correct Answer: C
Rationale: The correct answer is C because reapplying a condom catheter for a client with urinary incontinence is a task that can be safely delegated to assistive personnel (AP). This task involves a straightforward procedure that does not require advanced nursing skills or critical thinking. The nurse can provide clear instructions and oversee the AP's performance.
Choice A is incorrect because feeding a client with aspiration pneumonia requires close monitoring by a nurse due to the risk of complications. Choice B is incorrect as reinforcing teaching for a client learning to walk with a quad cane involves assessing the client's understanding and progress, which is within the nurse's scope. Choice D is incorrect because applying a sterile dressing to a pressure ulcer requires sterile technique and assessment of wound healing, which should be done by a nurse.