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 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 determine the infusion rate, we first calculate the total volume of the solution to be infused (100 mL) over the total time (1 hr). Therefore, the infusion pump should be set to deliver 100 mL/hr (Choice C). This ensures the correct administration of potassium chloride 10 mEq IV over 1 hr. Choices A, B, and D are incorrect because they do not accurately reflect the infusion rate required for the specified dose and time frame.
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A nurse is teaching a client who has Graves' disease about recognizing the manifestations of thyroid storm. Which of the following findings should the nurse include in the teaching?
- A. Lethargy
- B. Hypotension
- C. Decreased heart rate
- D. Increased temperature
Correct Answer: D
Rationale: The correct answer is D: Increased temperature. In thyroid storm, there is excessive thyroid hormone production leading to hyperthyroidism symptoms, including increased body temperature. Lethargy (A) is more indicative of hypothyroidism. Hypotension (B) is not a typical finding in thyroid storm; instead, hypertension is more common. Decreased heart rate (C) is also not a common manifestation as tachycardia is typically present in thyroid storm. Therefore, option D is the most appropriate manifestation to recognize in thyroid storm.
A nurse is admitting a client who has meningitis. Which of the following findings should the nurse expect?
- A. Photophobia
- B. Bradycardia
- C. Intermittent headache
- D. Petechiae on the chest
Correct Answer: A
Rationale: The correct answer is A: Photophobia. Photophobia, or sensitivity to light, is a common symptom of meningitis due to inflammation of the meninges surrounding the brain and spinal cord. This occurs because bright light can worsen the headache associated with meningitis. Bradycardia and petechiae on the chest are not typical findings in meningitis. Intermittent headache is vague and not specific to meningitis.
A nurse is caring for a client who has acute heart failure and received morphine IV 30 min ago. Which of the following findings should the nurse identify as an indication that the medication was effective?
- A. Decreased anxiety
- B. Emesis of 250 mL
- C. Increased respiratory rate to 26/min
- D. Decreased urinary output
Correct Answer: A
Rationale: The correct answer is A: Decreased anxiety. Morphine is often used to relieve pain and anxiety in patients with acute heart failure. The nurse should expect a reduction in anxiety as a positive response to the medication. Emesis (choice B) is not a typical indication of morphine effectiveness. Increased respiratory rate (choice C) may indicate respiratory depression, a potential adverse effect of morphine. Decreased urinary output (choice D) could suggest decreased cardiac output, which is not necessarily a sign of morphine effectiveness in this case.
A nurse is caring for a client receiving TPN. Which of the following actions should the
nurse take? For each potential nursing intervention, click to specify if the potential intervention
is anticipated, nonessential, or contraindicated for the client.
- A. Request a prescription for insulin
- B. Request for an antibitic to be administered
- C. Decrease the client's oxygen to 1.5 L/min via nasal canula
- D. Have 3 nurses verify the TPN solution prescription
- F. Notify the provider to increase TPN rate/hr
Correct Answer: A,B,C,D
Rationale: [
Anticipated: Request a prescription for insulin, Request for an antibiotic to be administered, Decrease the client's oxygen to 1.5 L/min via nasal cannula, Have 3 nurses verify the TPN solution prescription.
Rationale: A client on TPN may require insulin for glycemic control, antibiotics for infection management, oxygen adjustment for respiratory support, and verification of TPN solution to prevent errors.
Non-essential/Contraindicated: Not applicable as all options are essential in the care of a client receiving TPN.]
A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect?
- A. Photophobia
- B. Bradycardia
- C. Intermittent headache
- D. Petechiae on the chest
Correct Answer: A
Rationale: The correct answer is A: Photophobia. Meningitis is an inflammation of the meninges, the protective membranes covering the brain and spinal cord. Photophobia, or sensitivity to light, is a classic symptom of meningitis due to the irritation of the meninges causing increased sensitivity to light. This occurs because the inflamed meninges lead to stimulation of the nerves around the brain, resulting in discomfort when exposed to light.
Bradycardia (B) is not typically associated with meningitis. Intermittent headache (C) is vague and can be present in various conditions. Petechiae on the chest (D) are more commonly seen in conditions like meningococcal meningitis.