A nurse is preparing to administer 500 mL of an I.V. solution to a child over 12 hours via tubing that delivers microdrips at 60 gtt/mL. At what rate should the nurse infuse the solution?
- A. 42 gtt/minute.
- B. 83 gtt/minute.
- C. 60 gtt/minute.
- D. 21 gtt/minute.
Correct Answer: A
Rationale: Calculate: 500 mL over 12 hours = 41.67 mL/hour. For microdrip (60 gtt/mL), 41.67 mL/hour ×60 gtt/mL = 2500 gtt/hour ÷ 60 minutes = 41.67 gtt/minute, rounded to 42 gtt/minute.
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Which action is included in the accurate procedure for administering heparin sodium subcutaneously?
- A. Injecting the medication via an infusion device
- B. Massaging the injection site after administration
- C. Injecting the medication 1 inch from the umbilicus
- D. Avoiding aspiration before administration of the medication
Correct Answer: D
Rationale: Aspiration before administration of heparin sodium, an anticoagulant, should be avoided. Heparin administered by the subcutaneous route does not require an infusion device. The injection site is above the iliac crest or in the abdominal fat layer. It is injected at least 2 inches from the umbilicus. After administration, the needle is withdrawn, pressure is applied to the injection site, but the site is not massaged. Injection sites are rotated.
Pelvic inflammatory disease is most often caused by:
- A. Trichomoniasis
- B. E. coli
- C. Staphylococcus aureus
- D. Neisseria gonorrhoeae
Correct Answer: D
Rationale: Neisseria gonorrhoeae is a common cause of pelvic inflammatory disease, often resulting from untreated gonorrhea, leading to infection of the reproductive organs.
Which of the following assessment finding is expected in a client with bacterial pneumonia?
- A. Increased fremitus.
- B. Bilateral expiratory wheezing.
- C. Resonance on percussion.
- D. Vesicular breath sounds.
Correct Answer: A
Rationale: Increased fremitus is expected in bacterial pneumonia due to lung consolidation.
You are caring for a postoperative client who is complaining of abdominal distention and flatus. Which intervention would you most likely do for this client?
- A. A cleansing enema
- B. A retention enema
- C. A return-flow enema
- D. A laxative
Correct Answer: C
Rationale: A return-flow enema is specifically used to relieve abdominal distention and flatus by introducing and then removing fluid to stimulate gas expulsion.
A client with emphysema is receiving continuous oxygen therapy. Depressed ventilation is likely to occur unless the nurse ensures that the oxygen is administered in which of the following ways?
- A. Cooled.
- B. Humidified.
- C. At a low flow rate.
- D. Through nasal cannula.
Correct Answer: C
Rationale: Low flow rate oxygen prevents CO2 retention in emphysema clients, reducing the risk of depressed ventilation.
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