Nokea
A nurse is preparing to administer 0.9% sodium chloride 750 ml IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many ml/hr? (Round to nearest whole number)
- A. 105
- B. 107
- C. 110
- D. 115
Correct Answer: B
Rationale: 107 ml/hr. Calculation: 750 ml ÷ 7 hr = 107.14 ml/hr, rounded to 107.
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Which condition is a risk factor for pulmonary embolism?
- A. Dehydration
- B. Hypotension
- C. Bradycardia
- D. Fever
Correct Answer: A
Rationale: Dehydration increases blood viscosity, promoting clot formation and pulmonary embolism risk, more than hypotension, bradycardia, or fever.
A nurse is assessing an older client’s risk for falls. Which of the following assessments should the nurse use to identify the client’s safety needs? (Select ONE that does not apply)
- A. Lacrimal apparatus
- B. Pupil clarity
- C. Appearance of bulbar conjunctivae
- D. Visual fields
Correct Answer: A
Rationale: Pupil clarity, Visual fields, Visual acuity.
The nurse wants to delegate the Yankauer suctioning of a client to UAP. What will the nurse ensure that UAP know before delegating this activity?
- A. How to apply suction during the insertion of the catheter
- B. Not to apply suction during the insertion of the catheter
- C. How to maintain sterile technique
- D. How to listen for lung sounds
Correct Answer: B
Rationale: Yankauer suctioning (oral) is nonsterile and delegable to UAP. Not applying suction during insertion (B) prevents mucosal trauma a key point for UAP training. Applying suction during insertion (A) is incorrect. Sterile technique (C) is unnecessary for oral suctioning. Listening for lung sounds (D) is beyond UAP scope making B essential for safe delegation.
A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings, and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea?
- A. The client is receiving formula at room temperature
- B. The feedings infuse at a slow, continuous drip over 8 hr each night
- C. The client’s caregiver washes out the feeding bag with warm water once every 24 hr
- D. The client’s caregiver flushes the tubing with water before and after administering medications.
Correct Answer: C
Rationale: The client’s caregiver washes out the feeding bag with warm water once every 24 hr. Feeding bags should be washed out after each feeding and replaced with a new feeding bag every 24 hr to prevent bacterial contamination.
Which patient does the LPN/LVN identify at high risk for hospital-acquired pneumonia?
- A. A 35-year-old patient using the incentive spirometer following abdominal surgery
- B. A 55-year-old patient who is eating in the chair following a rhinoplasty
- C. A 40-year-old patient who refuses to cough and deep breath following a splenectomy
- D. A 24-year-old patient ambulating in the hall following an appendectomy
Correct Answer: C
Rationale: This patient is at high risk for hospital-acquired pneumonia. After a splenectomy (removal of the spleen), patients may experience pain and discomfort, which can make them reluctant to perform necessary activities like coughing and deep breathing. These activities are crucial for preventing lung complications such as atelectasis and pneumonia.