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 observes an AP reprimanding a client for not using the urinal properly. The AP tells him she will put a diaper on him if he does not use the urinal more carefully next time. Which of the following torts is the AP committing?
- A. "Assault"
- B. Battery
- C. False imprisonment
- D. Invasion of privacy
Correct Answer: A
Rationale: The correct answer is A: "Assault." Assault is the intentional act that creates fear of imminent harmful or offensive contact. In this scenario, the AP's threat of putting a diaper on the client if he does not use the urinal properly next time constitutes assault as it instills fear in the client. Choice B, Battery, involves actual harmful or offensive contact, which is not present here. Choice C, False Imprisonment, involves restricting someone's freedom of movement, which is not happening in this scenario. Choice D, Invasion of Privacy, is not applicable as the situation does not involve a violation of the client's privacy.
A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via NG tube. Which of the following is an appropriate nursing action prior to administering the tube feeding? Select all.
- A. Auscultate bowel sounds.
- B. Assist the client to an upright position.
- C. Test the pH of gastric aspirate.
- D. Warm the formula to body temperature.
- E. Discard any residual gastric contents.
Correct Answer: A, B, C
Rationale: Correct Answer: A, B, C
Rationale:
A: Auscultating bowel sounds is important to assess gastrointestinal motility and ensure the client is ready to receive the feeding.
B: Assisting the client to an upright position helps prevent aspiration during feeding by promoting proper tube placement.
C: Testing the pH of gastric aspirate confirms tube placement in the stomach and prevents potential complications from feeding into the lungs.
Summary:
D: Warming the formula is not necessary before administration and can lead to bacterial growth.
E: Discarding residual gastric contents should be done after assessing the pH, not before.
The skin barrier covering a client's intestinal fistula keeps falling off when she stands up to ambulate. The nurse has reapplied it twice during the shift, but it remains intact only when the client is supine in bed. The nurse telephoned the physical therapist about the difficulties containing the drainage from the fistula, so the therapist didn't ambulate the client today. The client sat in a chair during lunch w/an absorbent pad over the fistula. The client ate all the food on her tray. The wound care nurse confirmed that she will see the client later today. The client states she feels frustrated at not having physical therapy, but the nurse thinks the client welcomed having a day to rest. Which of the following information should the nurse include in the change-of-shift report? Select all.
- A. The physical therapist didn't ambulate the client today
- B. The skin barrier's seal stays on in bed but loosens when the client stands.
- C. The client seemed to welcome having a 'day off' from physical therapy
- D. The wound care nurse will see the client later today
- E. The client ate all the food on her lunch tray
Correct Answer: A, B, D
Rationale: The correct choices to include in the change-of-shift report are A, B, and D. Choice A is important to communicate as it highlights that the physical therapist did not ambulate the client due to difficulties with the skin barrier and fistula drainage. Choice B is crucial as it explains the specific issue with the skin barrier, emphasizing that it stays intact when the client is supine but loosens when standing. Choice D is essential to include as it informs about the upcoming visit from the wound care nurse. Choices C and E, although relevant to the client's well-being, are not directly related to the current care plan and should not be included in the report.
A nurse is caring for an 82-year-old client in the ER who has an oral body temperature of 38.3°C (101°F), a pulse rate of 114/min, & a respiratory rate of 22/min. He is restless & his skin is warm. Which of the following are appropriate nursing interventions for this client? Select all.
- A. Obtain culture specimens before initiating antimicrobials
- B. Restrict the client's oral fluid intake
- C. Encourage the client to limit activity & rest
- D. Allow the client to shiver to dispel excess heat
- E. Assist the client with oral hygiene frequently
Correct Answer: A, C, E
Rationale: Correct Answer: A, C, E
Rationale:
A: Obtaining culture specimens before initiating antimicrobials is crucial to identify the specific pathogen causing the infection and guide appropriate treatment.
C: Encouraging the client to limit activity & rest helps conserve energy and promote recovery in the presence of infection.
E: Assisting the client with oral hygiene frequently helps prevent further infection and maintain oral health, which is important in the elderly population.
Incorrect Choices:
B: Restricting the client's oral fluid intake is not appropriate as hydration is essential, especially in the presence of fever and infection.
D: Allowing the client to shiver to dispel excess heat is not recommended as it can lead to increased metabolic demand and discomfort for the client.
A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following is the body's priority energy reserve?
- A. Fat
- B. Protein
- C. Glycogen
- D. Carbohydrates
Correct Answer: D
Rationale: The correct answer is D: Carbohydrates. Carbohydrates are the body's priority energy reserve because they are the primary source of energy for the body, especially during high-intensity activities like sports. When consumed, carbohydrates are broken down into glucose, which is used for immediate energy or stored as glycogen in muscles and the liver for later use. Fat is a long-term energy reserve but is not as readily accessible as carbohydrates for quick energy. Protein is primarily used for building and repairing tissues, not as a main energy source. Glycogen is a stored form of carbohydrates in the body, not the primary energy reserve.