Nokea
A nurse is preparing to administer dextrose 5% in 0.45% sodium chloride IV to infuse at 100 mL/hr. The nurse is using microtubing. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round to the nearest whole number)
Correct Answer: 100
Rationale: The correct answer is 100 gtt/min. To calculate the IV flow rate in gtt/min for microtubing, you can use the formula: gtt/min = (mL/hr x tubing factor) / 60. In this case, the mL/hr is 100, and for microtubing, the tubing factor is usually 60. So, (100 x 60) / 60 = 100 gtt/min. This ensures the dextrose 5% in 0.45% sodium chloride solution is infused at the correct rate. Other choices would be incorrect because they do not follow the correct calculation for microtubing flow rates.
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A nurse is assessing a client who has schizophrenia and has been on long-term treatment with chlorpromazine. He notes the client is experiencing some involuntary movements of the tongue and face. The nurse should suspect the client has developed which of the following adverse effects?
- A. Akathisia
- B. Tardive dyskinesia
- C. Dystonia
Correct Answer: B
Rationale: The correct answer is B: Tardive dyskinesia. Tardive dyskinesia is a common adverse effect of long-term antipsychotic medication use, such as chlorpromazine. It is characterized by involuntary movements of the tongue and face. This condition is often irreversible and can be distressing for the client. Akathisia (choice A) is a different extrapyramidal side effect characterized by restlessness and the urge to move constantly. Dystonia (choice C) is another extrapyramidal side effect that presents as sustained muscle contractions causing abnormal postures. In this case, the symptoms described in the question are more indicative of tardive dyskinesia due to the specific type of involuntary movements observed in the client.
A nurse is preparing to administer fluconazole 400 mg by intermittent IV bolus daily. Available is fluconazole 400 mg in 0.9% sodium chloride (NaCl) 200 mL to infuse over 2 hours. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest tenth/whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 100
Rationale: Correct Answer: 100
Rationale: To calculate the IV pump rate, use the formula: (Volume to be infused in mL) / (Time in hours). In this case, 200 mL over 2 hours. 200 / 2 = 100 mL/hr.
Summary:
A. Incorrect. Not the correct calculation for the IV pump rate.
B. Incorrect. Not the correct calculation for the IV pump rate.
C. Incorrect. Not the correct calculation for the IV pump rate.
D. Incorrect. Not the correct calculation for the IV pump rate.
E. Incorrect. Not the correct calculation for the IV pump rate.
F. Incorrect. Not the correct calculation for the IV pump rate.
G. Incorrect. Not the correct calculation for the IV pump rate.
A nurse enters a client’s room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take?
- A. Place a pillow under the client’s head.
- B. Insert a padded tongue blade into the client’s mouth.
- C. Apply a face mask for oxygen administration.
- D. Gently restrain the client’s extremities.
Correct Answer: A
Rationale: The correct action is to place a pillow under the client's head. This helps to protect the client's head from injury during the seizure. It is important to maintain a patent airway and prevent head injury. Inserting a padded tongue blade (choice B) could cause injury or obstruct the airway. Applying a face mask for oxygen (choice C) may not be necessary at this point and can be done after the seizure stops. Gently restraining the client's extremities (choice D) can cause further injury. It is crucial to prioritize safety and comfort during a seizure.
A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?
- A. Handrails are present in the bathroom.
- B. Electrical cords are placed along the walls.
- C. Uses a microwave for cooking.
- D. Scatter rugs are present in the kitchen.
Correct Answer: D
Rationale: The correct answer is D: Scatter rugs are present in the kitchen. Scatter rugs can pose a safety risk for an older adult with decreased vision due to glaucoma as they increase the risk of tripping and falling. The uneven surface and lack of secure placement make scatter rugs hazardous. Handrails in the bathroom (A) enhance safety, electrical cords along the walls (B) may be a tripping hazard but can be easily addressed, and using a microwave for cooking (C) is a safe and convenient option for someone with decreased vision.
A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect?
- A. Blurred vision
- B. Severe headache
- C. Oriented to person, place, and year
- D. Bradycardia
Correct Answer: B
Rationale: The correct answer is B: Severe headache. Meningitis commonly presents with severe headache due to inflammation of the meninges. This is a classic symptom and should be expected during assessment. Blurred vision (A) is not a typical finding in meningitis. Being oriented to person, place, and year (C) is a sign of intact mental status, which may not be present in someone with meningitis. Bradycardia (D) is not a common finding in meningitis; tachycardia is more likely due to the body's response to infection.