Nokea
A nurse is preparing to administer lactated Ringer's (LR) IV 100 mL over 15 minutes. The nurse should set the infusion pump to deliver how many mL/hr?
Correct Answer: 400
Rationale: The correct answer is 400 mL/hr. To calculate the mL/hr rate, we first convert the 15 minutes to hours (15 minutes ÷ 60 minutes = 0.25 hours). Then, we divide the total volume (100 mL) by the time in hours (100 mL ÷ 0.25 hours = 400 mL/hr). This rate ensures the safe and accurate administration of 100 mL of LR over a 15-minute period. Other choices are incorrect because they do not accurately calculate the mL/hr rate based on the given parameters.
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A nurse is instructing a group of nursing students in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? Select all.
- A. Place the client in semi-Fowler's position
- B. Have the client rest an arm across the abdomen
- C. Observe one full respiratory cycle before counting the rate
- D. Count the rate for one minute if it is regular
- E. Count & report any sighs the client demonstrates
Correct Answer: A, B, C
Rationale: The correct guidelines for measuring a client's respiratory rate are to place the client in semi-Fowler's position, have the client rest an arm across the abdomen, and observe one full respiratory cycle before counting the rate. Placing the client in semi-Fowler's position helps with optimal lung expansion and breathing efficiency. Having the client rest an arm across the abdomen can help the nurse visualize the rise and fall of the chest more clearly. Observing one full respiratory cycle before counting the rate ensures accuracy in counting. These guidelines are essential for obtaining an accurate respiratory rate. Choices D and E are incorrect as counting for one minute is unnecessary if the rate is regular, and counting and reporting sighs is not part of the respiratory rate measurement process.
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.
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 delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP?
- A. "The roommate is up independently"
- B. The client ambulates w/his slippers on over his antiembolic stockings
- C. The client uses a front-wheeled walker when ambulating
- D. The client had pain medication 30 min ago
- E. The client is allergic to codeine
Correct Answer: B, C, D
Rationale: Correct Answer: B, C, D
Rationale:
- Option B: The client should not wear slippers over antiembolic stockings as it can increase the risk of slipping or falling.
- Option C: Knowing that the client uses a front-wheeled walker is crucial for safe ambulation post-knee arthroplasty.
- Option D: Advising on the timing of pain medication helps ensure the client is comfortable during ambulation.
Summary:
- Option A is incorrect because the roommate's ambulation status is irrelevant to the client's care.
- Option E is incorrect as the client's allergy to codeine does not directly impact safe ambulation post-knee arthroplasty.
A nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following information should the nurse include? Select all.
- A. Older adults are more prone to dehydration than younger adults.
- B. Older adults need the same amount of most vitamins and minerals as younger adults.
- C. Many older men and women need calcium supplementation.
- D. Older adults need more calories than they did when they were younger.
- E. Older adults should consume a diet low in carbohydrates.
Correct Answer: A, B, C
Rationale: The correct answer is A, B, and C.
A: Older adults are more prone to dehydration due to age-related physiological changes that decrease the body's ability to conserve water.
B: While older adults generally need the same amount of vitamins and minerals as younger adults, they may require higher amounts of certain nutrients like vitamin D and calcium.
C: Many older men and women may need calcium supplementation to prevent osteoporosis and maintain bone health.
Incorrect choices:
D: Older adults typically need fewer calories as they age due to decreased metabolism and physical activity.
E: There is no specific recommendation for older adults to consume a diet low in carbohydrates, as carbohydrates are an essential energy source.