Nokea
A nurse is preparing to administer Ringer's lactate via continuous IV infusion at a rate of 120 mL/hr. The manual IV tubing's drop factor is 60 gtt/mL. How many gtt/min should the nurse set the manual IV infusion to deliver? How many gtt/min for Ringer's lactate infusion?
Correct Answer: 120
Rationale: The correct answer is 120 gtt/min. To calculate the infusion rate in gtt/min, you first convert the hourly rate to minutes by dividing 120 mL/hr by 60 min/hr, which equals 2 mL/min. Then, multiply the mL/min by the drop factor of 60 gtt/mL to get the answer of 120 gtt/min. This ensures the correct amount of Ringer's lactate is delivered per minute. Other choices are incorrect because they do not follow the correct calculation steps or involve incorrect conversions, leading to inaccurate infusion rates.
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A nurse is caring for a patient who has a new prescription for gabapentin. Which of the following adverse effects should the nurse monitor for? Which adverse effect should the nurse monitor for gabapentin?
- A. Drowsiness
- B. Hypertension
- C. Diarrhea
- D. Tachycardia
Correct Answer: A
Rationale: The correct answer is A: Drowsiness. Gabapentin is known to cause central nervous system side effects, such as drowsiness, dizziness, and fatigue. The nurse should monitor the patient for signs of drowsiness as it can impact their daily activities and safety. Hypertension (B), diarrhea (C), and tachycardia (D) are not commonly associated with gabapentin use. Therefore, the nurse should primarily focus on monitoring for drowsiness as the most likely adverse effect.
A nurse is caring for a patient who wants to know how albuterol aids his breathing. What should the nurse's response be? How does albuterol aid breathing?
- A. The medication will decrease coughing episodes.
- B. The medication will prevent wheezing.
- C. The medication will open the airways.
- D. The medication will stimulate the flow of mucus.
- E. The medication will reduce inflammation.
Correct Answer: B,C
Rationale: The correct answers are B and C. Albuterol aids breathing by preventing wheezing (choice B) and opening the airways (choice C). Albuterol is a bronchodilator that works by relaxing the muscles around the airways, allowing them to widen and making it easier to breathe. Choices A, D, and E are incorrect because albuterol does not directly decrease coughing episodes, stimulate mucus flow, or reduce inflammation. The key is understanding albuterol's mechanism of action in dilating the airways to improve breathing.
A nurse is educating a patient about the risk factors for osteoarthritis. Which factors should the nurse include in the education? Which factors should the nurse include for osteoarthritis risk?
- A. Bacteria
- B. Diuretics
- C. Aging
- D. Obesity
Correct Answer: C,D
Rationale: The correct answers are C: Aging and D: Obesity. Aging is a well-established risk factor for osteoarthritis as wear and tear on the joints accumulates over time. Obesity increases stress on weight-bearing joints, leading to accelerated joint degeneration. Bacteria (A) and diuretics (B) are not directly linked to osteoarthritis development.
A nurse is planning a meal for a patient who has diverticulitis. Which menu selection should the nurse include in the plan? Which menu is suitable for diverticulitis?
- A. Sliced ham with green salad.
- B. Grilled chicken breast with white rice.
- C. Turkey sandwich with celery sticks.
- D. Pork tenderloin with green peas.
Correct Answer: B
Rationale: The correct answer is B: Grilled chicken breast with white rice. This choice is suitable for diverticulitis because it is low in fiber, which helps reduce irritation to the digestive system. High-fiber foods like green salad, celery sticks, green peas, and whole grain bread from the turkey sandwich can aggravate diverticulitis symptoms. Pork tenderloin may be too fatty for some individuals with diverticulitis, making grilled chicken a better option. White rice is easily digestible and less likely to cause discomfort compared to whole grains.
Medication Administration Record
• 1700: Dextrose 5% in 0.45% sodium chloride (D5/0.45% NaCl) at 100 mL/hr
• 1700: Promethazine 25 mg IV bolus every 4 hours PRN for nausea/vomiting
• 1715: Morphine 4 mg IV bolus every 6 hours PRN for pain
• 2115: Acetaminophen 625 mg PO every 6 hours PRN if temperature > 38.6°C (101.5°F)
• Discontinue Morphine (Note: The morphine has not yet been administered as the order is due in the future.)
Nurses' Notes
The client was received from the Post Anesthesia Care Unit (PACU) with initial vital signs recorded. The client is drowsy but arouses to verbal stimuli and is oriented to person, place, and time. The client is able to move all extremities and follow simple commands.
The heart rhythm is normal sinus, bilateral radial and pedal pulses are +2, and capillary refill is less than 2 seconds. Respiratory rate is 18/min with clear lung sounds and oxygen saturation of 96% on 2 L via nasal cannula. Bowel sounds are hypoactive in all four quadrants. The indwelling urinary catheter is draining clear yellow urine. The dressing on the right knee is dry and intact, with no drainage noted.
At 1830, the client was repositioned for comfort with side rails up x2 and the call light within reach. The client remains somewhat lethargic but arouses easily and reports nausea and pain, rating the pain as 6 on a scale from 0 to 10. Metoclopramide 10 mg IV was administered at 1830 for nausea. The client is positioned comfortably with the side rails up and call light within reach.
Physical Examination
• Heart Rate: 88/min
• Respiratory Rate: 18/min
• Blood Pressure: 115/55 mm Hg
• Temperature: 36.4°C (97.5°F)
• Oxygen Saturation: 96% on 2 L via nasal cannula
• General Behavior: Drowsy but arouses easily, somewhat lethargic
• Pain Level: Rated as 6 on a scale from 0 to 10
• Bowel Sounds: Hypoactive in all four quadrants
• Urinary Output: Clear yellow urine from indwelling catheter
• Knee Dressing: Dry and intact with no drainage
A nurse is caring for a client who is 6 hours postoperative following a right knee arthroplasty. The client has been receiving medications and fluids as outlined below.Exhibits Complete the following sentence by selecting the most appropriate action from the choices below:
The nurse should first:---------------------,followed by--------------------------------------
- A. Administer additional morphine for pain management
- B. Reposition the client for comfort
- C. Assess the area where the restraint is to be placed on the client
- D. Pad the client’s wrists under the restrain
- E. Ensure the client’s call light is within reach
Correct Answer: A,B
Rationale: Action to Take: A, B; Potential Condition: Postoperative pain; Parameter to Monitor: Pain level, Client comfort.
Rationale: After a knee arthroplasty, pain management is crucial for the client's comfort and recovery. Administering additional morphine (A) addresses postoperative pain. Repositioning the client (B) is important to prevent complications such as pressure ulcers. Assessing the area for the restraint (C) and padding the client's wrists (D) are not immediate priorities. Ensuring the call light is within reach (E) is important but not the first action to take.