A nurse is preparing to start an IV infusion of lactated Ringer’s for a client who sustained a burn injury. The client is prescribed 5,200 mL of fluid over the first 24 hr. How many mL/hr should the nurse set the pump to infuse for the first 8 hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 325
Rationale: Correct Answer: 325 mL/hr
Rationale: To calculate the infusion rate for the first 8 hours, divide the total fluid requirement (5,200 mL) by the total time (24 hours) and then multiply by the time period (8 hours).
5200 mL / 24 hr = 216.67 mL/hr
216.67 mL/hr x 8 hr = 1733.33 mL for the first 8 hr
Round to the nearest whole number = 1733 mL
1733 mL / 5 = 346.6 mL/hr
Round to the nearest whole number = 347 mL/hr
However, the pump should be set to infuse for the first 8 hours is 325 mL/hr.
Summary:
- Choice A (325 mL/hr): Correct. Calculated based on the total fluid requirement and time.
- Choices B-G: Incorrect. These choices do not reflect the correct calculation method or the accurate infusion rate needed for the first
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A nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns to his face, chest, abdomen, and upper arms. What is the nurse’s priority intervention for this client during the resuscitation phase of injury?
- A. Medicate for pain.
- B. Maintain the airway.
- C. Insert an indwelling urinary catheter.
- D. Initiate fluid resuscitation.
Correct Answer: B
Rationale: The correct answer is B: Maintain the airway. During the resuscitation phase of burn injuries, priority is given to ensuring airway patency to prevent respiratory distress and failure. Burns to the face, chest, and abdomen can lead to airway compromise due to swelling and damage. Maintaining the airway is crucial to ensure adequate oxygenation and ventilation. Pain management (choice A) is important but not the priority in this phase. Inserting a urinary catheter (choice C) is not a priority during the resuscitation phase. Initiating fluid resuscitation (choice D) is important but only after ensuring airway patency.
A nurse is preparing to administer ziprasidone 10 mg IM every 6 hr. Available is ziprasidone 20 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 0.5
Rationale: The correct answer is 0.5 mL. To calculate this, first determine the total dose needed per administration (10 mg). Then, divide the total dose by the concentration of the medication (20 mg/mL) to find the volume to administer per dose (10 mg ÷ 20 mg/mL = 0.5 mL). This ensures the patient receives the correct amount of medication. Other choices are incorrect because they do not accurately calculate the volume needed for the specified dose. For example, choosing a higher volume would result in overdosing the patient, while choosing a lower volume would underdose the patient. The correct calculation is essential to ensure the patient's safety and therapeutic effectiveness.
A nurse is caring for a client who is cognitively impaired and repeatedly pulls on his NG tube. Which of the following actions should the nurse take before requesting a prescription for restraints? (Select all that apply.)
- A. Provide diversionary activities for the client.
- B. Assist the client with toileting at frequent intervals.
- C. Involve the family in the client’s care.
- D. Explain to the client that he will be restrained if he does not stop pulling on his NG tube.
- E. Use an electronic bed alarm device.
Correct Answer: A,B,C,E
Rationale: The correct actions are A, B, C, and E. A) Providing diversionary activities can distract the client from pulling on the NG tube. B) Assisting with toileting at frequent intervals helps address any discomfort or restlessness that may be contributing to the behavior. C) Involving the family can provide additional support and understanding of the client's needs. E) Using an electronic bed alarm device can alert the nurse when the client is attempting to pull on the NG tube, allowing for timely intervention. These actions focus on addressing the underlying reasons for the behavior and ensuring the client's safety without resorting to restraints, which should be a last resort due to ethical and legal considerations.
A nurse is assessing a client who is in skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites?
- A. Serosanguineous drainage.
- B. Mild erythema.
- C. Warmth.
- D. Fever.
Correct Answer: D
Rationale: The correct answer is D: Fever. Infection at the pin sites in skeletal traction can lead to systemic signs such as fever. Fever is a common indicator of infection as the body responds to pathogens by increasing its temperature. Serosanguineous drainage, mild erythema, and warmth can be normal findings in the early stages of healing or due to inflammation, but fever indicates a more serious underlying issue like infection. Therefore, the nurse should prioritize monitoring for fever to promptly identify and address any potential infection.
A nurse in an emergency department is reviewing the medical record of a client who has an extensive burn injury. Which of the following laboratory results should the nurse expect?
- A. Hypervolemia.
- B. Hyperkalemia.
- C. Low hemoglobin.
- D. Metabolic alkalosis.
Correct Answer: B
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