Nokea
A nurse is preparing to administer lactated Ringer's (LR) 1,000 mL IV to infuse over 8 hr. 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? (Round the answer to the nearest whole number).
- A. 21 gtt/min
- B. 20 gtt/min
- C. 25 gtt/min
- D. 18 gtt/min
Correct Answer: A
Rationale: To calculate the IV infusion rate in gtt/min: 1000 mL / 480 min 10 gtt/mL = 20.83 ≈ 21 gtt/min. Therefore, the correct answer is A. Choice B (20 gtt/min) is incorrect because the calculation results in 20.83 gtt/min, rounded to 21. Choices C (25 gtt/min) and D (18 gtt/min) are incorrect as they are not the closest whole number approximation to the calculated value.
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A nurse is caring for a client who has a prescription for chlorothiazide to treat hypertension. The nurse should plan to monitor the client for which of the following adverse effects?
- A. Thrombophlebitis
- B. Hyperactive reflexes
- C. Muscle weakness
- D. Hypoglycemia
Correct Answer: C
Rationale: The correct answer is C: Muscle weakness. Chlorothiazide, a thiazide diuretic, can lead to hypokalemia, which can cause muscle weakness. Thrombophlebitis (choice A) is not typically associated with chlorothiazide use. Hyperactive reflexes (choice B) and hypoglycemia (choice D) are also not commonly linked to this medication. Therefore, monitoring for muscle weakness is crucial when a client is prescribed chlorothiazide.
A nurse is preparing to administer iron dextran IV to a client. Which of the following actions should the nurse plan to take?
- A. Administer a small test dose before giving the full dose
- B. Infuse the medication over 30 seconds
- C. Monitor client closely for hypertension
- D. Administer cyanocobalamin as an antidote if toxicity occurs
Correct Answer: A
Rationale: The correct action the nurse should plan to take when preparing to administer iron dextran IV is to administer a small test dose before giving the full dose. This is done to assess for any allergic reactions that the client may have to the medication. Choice B is incorrect because iron dextran should be infused slowly over a longer period, typically over 1-2 hours to reduce the risk of adverse reactions. Choice C is incorrect because iron dextran administration is more commonly associated with hypotension rather than hypertension. Choice D is incorrect because cyanocobalamin is not used as an antidote for iron dextran toxicity; instead, treatment for iron toxicity may involve supportive care, chelation therapy, or in severe cases, iron antidotes like deferoxamine.
A nurse is providing teaching to a client who has a new prescription for hydrochlorothiazide 50 mg PO daily to treat hypertension. Which of the following instructions should the nurse include in the teaching?
- A. Take hydrochlorothiazide as needed for edema.
- B. Check your weight once weekly.
- C. Take the hydrochlorothiazide on an empty stomach.
- D. Take the hydrochlorothiazide in the morning.
Correct Answer: D
Rationale: The correct answer is to take hydrochlorothiazide in the morning. This medication is usually advised to be taken in the morning to prevent nocturia, which is excessive urination at night. Option A is incorrect because hydrochlorothiazide should be taken daily as prescribed, not as needed for edema. Option B is incorrect as monitoring weight weekly may not be specifically related to hydrochlorothiazide therapy. Option C is incorrect as hydrochlorothiazide does not need to be taken on an empty stomach.
A nurse in an outpatient facility is assessing a client who is prescribed furosemide 40mg daily, but the client reports she has been taking extra doses to promote weight loss. Which of the following indicates she is dehydrated?
- A. Urine specific gravity of 1.035
- B. Urine specific gravity of 444
- C. Urine specific gravity of 2000
- D. Urine specific gravity of 1111.1
Correct Answer: A
Rationale: A urine specific gravity greater than 1.030 indicates dehydration. In this case, a urine specific gravity of 1.035 suggests concentrated urine, indicating dehydration. Choices B, C, and D have values that are not within the normal range for urine specific gravity and do not indicate dehydration. A urine specific gravity of 444, 2000, or 1111.1 are not physiologically possible values and are therefore incorrect.
A nurse is caring for a client who has a new prescription for enalapril. The nurse should monitor the client for which of the following adverse effects of this medication?
- A. Ecchymosis
- B. Jaundice
- C. Hypotension
- D. Hypokalemia
Correct Answer: C
Rationale: The correct answer is C: Hypotension. Enalapril, an ACE inhibitor, can lead to hypotension, especially after the first dose. Choices A, B, and D are incorrect because enalapril is not typically associated with ecchymosis, jaundice, or hypokalemia as common adverse effects. Therefore, the nurse should primarily monitor the client for signs of hypotension.