Nokea
A nurse is preparing to administer potassium chloride 10 mEq IV over 1 hr to a client. Available is potassium chloride 10 mEq in 100 mL of 0.9% sodium chloride. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number.)
- A. 50 mL/hr
- B. 75 mL/hr
- C. 100 mL/hr
- D. 125 mL/hr
Correct Answer: C
Rationale: To calculate the infusion rate, we need to use the formula: (Desired dose ÷ Volume) x 60 minutes. In this case, the desired dose is 10 mEq over 1 hour, and the volume is 100 mL.
So, (10 ÷ 100) x 60 = 6 mL/hr. Therefore, the nurse should set the infusion pump to deliver 100 mL/hr. This ensures the correct administration of potassium chloride over the specified time frame.
Choice A (50 mL/hr) and B (75 mL/hr) are incorrect as they would result in the underdosing of potassium chloride. Choice D (125 mL/hr) is incorrect as it would result in the overdosing of potassium chloride. The correct answer, C (100 mL/hr), ensures the proper administration of the medication within the specified parameters.
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A nurse is providing teaching for a client who has constipation-predominant irritable bowel syndrome (IBS-C). Which of the following statements should the nurse include in the teaching?
- A. Take stimulant laxatives daily to relieve constipation.
- B. Avoid fiber-rich foods to prevent bloating.
- C. Increase water intake and use bulk-forming laxatives.
- D. Eat a low-carbohydrate diet to reduce symptoms.
Correct Answer: C
Rationale: The correct answer is C: Increase water intake and use bulk-forming laxatives. This is because increasing water intake helps soften stool, making it easier to pass, and bulk-forming laxatives add bulk to stool, aiding in bowel movements for individuals with IBS-C. Stimulant laxatives (A) can lead to dependency and worsen symptoms. Avoiding fiber-rich foods (B) can exacerbate constipation. Eating a low-carbohydrate diet (D) may not directly address the constipation associated with IBS-C.
A nurse is providing discharge teaching to a client following a loop electrosurgical excision procedure (LEEP) for the treatment of cervical cancer. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should expect heavy bleeding for the next week.
- B. I will avoid using tampons for the next few weeks.
- C. I should resume sexual activity within 24 hours.
- D. I will avoid all physical activity for a month.
Correct Answer: B
Rationale: The correct answer is B: "I will avoid using tampons for the next few weeks." This statement indicates an understanding of the discharge teaching because using tampons can introduce bacteria into the healing cervix, increasing the risk of infection post-LEEP. Choosing this answer demonstrates knowledge of the importance of maintaining good hygiene and minimizing infection risk during the healing process.
Other choices are incorrect:
A: Expecting heavy bleeding for the next week is incorrect as heavy bleeding should decrease gradually.
C: Resuming sexual activity within 24 hours is incorrect as it can increase the risk of infection and disrupt the healing process.
D: Avoiding all physical activity for a month is incorrect as light activities are usually allowed, and complete inactivity can lead to complications like blood clots.
A home health nurse is inspecting a clients residence for electrical hazards as part of the agencys quality improvement plan. Which of the following findings should the nurse identify as a safety hazard?
- A. An IV pump is plugged into an outlet near a sink.
- B. A lamp with a short cord is used in the bedroom.
- C. A television is plugged into a surge protector.
- D. The client uses a nightlight in the hallway.
Correct Answer: A
Rationale: Correct Answer: A. An IV pump is plugged into an outlet near a sink.
Rationale: Plugging an IV pump near a sink poses a significant risk of electrical shock due to water exposure. Water conducts electricity and can lead to electrocution. This situation directly violates electrical safety guidelines.
Summary of other choices:
B. A lamp with a short cord in the bedroom: While a short cord may not be ideal, it does not pose an immediate safety hazard unless it is frayed or damaged.
C. A television plugged into a surge protector: This is a safe practice as surge protectors help prevent damage from power surges and do not pose a direct safety hazard.
D. The client uses a nightlight in the hallway: Nightlights are commonly used for safety and do not typically pose an electrical hazard if used correctly.
A nurse is assessing a client for fluid volume deficit following lumbar spinal surgery. The nurse should identify which of the following findings as an indication the client is at risk for fluid volume deficit?
- A. Surgical drain output 300 mL during an 8-hr shift
- B. Bounding peripheral pulses
- C. Neck vein distention
- D. Weight gain of 2 kg (4.4 lb) in 24 hours
Correct Answer: A
Rationale: The correct answer is A: Surgical drain output 300 mL during an 8-hr shift. This finding indicates potential fluid loss, which can lead to fluid volume deficit. Surgical drain output is a direct measure of fluid loss from the body and can help assess the client's fluid status. Bounding peripheral pulses (B) and neck vein distention (C) are signs of fluid volume excess, not deficit. Weight gain of 2 kg (4.4 lb) in 24 hours (D) suggests fluid retention, not deficit.
A nurse is caring for a client who is receiving peritoneal dialysis. Which of the following actions should the nurse take?
- A. Report cloudy dialysate drainage to the provider.
- B. Lower the drainage bag below the level of the abdomen.
- C. Encourage fluid intake of 3L per day.
- D. Use sterile gloves only when removing the catheter.
Correct Answer: A
Rationale: The correct answer is A: Report cloudy dialysate drainage to the provider. Cloudy dialysate drainage can indicate infection, leading to peritonitis. The nurse should report this immediately for further evaluation and treatment to prevent complications. Lowering the drainage bag below the abdomen (B) can cause backflow, increasing the risk of contamination. Encouraging fluid intake of 3L per day (C) is a general recommendation but not specific to peritoneal dialysis. Using sterile gloves only when removing the catheter (D) is incorrect as sterile technique is required during all catheter manipulations in peritoneal dialysis.