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A primary health care provider prescribes 1000 mL of normal saline to infuse at 100 mL/hour. The drop factor is 10 drops/mL. The nurse should set the flow rate at how many drops per minute?
Correct Answer: 17
Rationale: It will take 10 hours for 1000 mL to infuse at 100 mL/hour (1000 mL ÷ 100 mL = 10 hour × 60 min = 600 min). Next, use the intravenous (IV) flow rate formula. Formula: Total volume × Drop factor ÷ Time in minutes. 1000 mL × 10 Drops/mL = 10,000 ÷ 600 min = 16.6, or 17 Drops/minute.
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The nurse admits a client who is in sickle cell crisis. The nurse should prepare for which intervention as a priority in the management of the client?
- A. Pain management with an opioid
- B. Intravenous fluid therapy
- C. Oxygen administration
- D. Blood transfusion
Correct Answer: C
Rationale: The priority nursing intervention for a client in sickle cell crisis is to administer supplemental oxygen because the client is hypoxemic, and as a result, the red blood cells change to the sickle shape. In addition, oxygen is the priority because airway and breathing are more important than circulatory needs. The nurse also plans for fluid therapy to promote hydration and reverse the agglutination of sickled cells, opioid analgesics for relief from severe pain, and blood transfusions (rather than iron administration) to increase the blood's oxygen-carrying capacity.
The nurse admits a client with a suspected diagnosis of bulimia nervosa. While performing the admission assessment, the nurse expects to elicit which data about the client's beliefs?
- A. Is accepting of body size
- B. Views purging as an accepted behavior
- C. Overeats for the enjoyment of eating food
- D. Overeats in response to losing control of diet
Correct Answer: B
Rationale: Individuals with bulimia nervosa develop cycles of binge eating, followed by purging. They seldom attempt to diet and have no sense of loss of control. Options 1, 3, and 4 are true of the obese person who may binge eat (not purge).
A client has developed atrial fibrillation resulting in a ventricular rate of 150 beats per minute. The nurse should assess the client for which effects of this cardiac occurrence? Select all that apply.
- A. Dyspnea
- B. Flat neck veins
- C. Nausea and vomiting
- D. Chest pain or discomfort
- E. Hypotension and dizziness
- F. Hypertension and headache
Correct Answer: A,D,E
Rationale: The client with uncontrolled atrial fibrillation with a ventricular rate over 100 beats per minute is at risk for low cardiac output caused by loss of atrial kick. The nurse should assess the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins. Neither headache nor nausea and vomiting are associated with the effects of uncontrolled atrial fibrillation.
The nurse is monitoring an unconscious client who sustained a head injury. Which observed positioning supports the suspicion that the client sustained an upper brainstem injury?
- A. Abnormal involuntary flexion of the extremities
- B. Abnormal involuntary extension of the extremities
- C. Upper extremity extension with lower extremity flexion
- D. Upper extremity flexion with lower extremity extension
Correct Answer: B
Rationale: Decerebrate posturing, which can occur with upper brainstem injury, is characterized by abnormal involuntary extension of the extremities. Options 1, 3, and 4 are incorrect descriptions of this type of posturing.
The nurse creates a discharge plan for a client who had an abdominal hysterectomy. Which activity instructions should the nurse include in the plan? Select all that apply.
- A. Avoid heavy lifting.
- B. Sit as much as possible.
- C. Take baths rather than showers.
- D. Limit stair climbing to five times a day.
- E. Gradually increase walking as exercise but stop before becoming fatigued.
- F. Avoid jogging, aerobic exercises, sports, or any strenuous exercise for 6 weeks.
Correct Answer: A,D,E,F
Rationale: After abdominal hysterectomy, the client should avoid lifting anything that is heavy and limit stair climbing to five times a day. The client should walk indoors for the first week and then gradually increase walking as exercise, but stop before becoming fatigued. The client should avoid jogging, aerobic exercises, sports, or any strenuous exercise for 6 weeks. The client is also told to avoid the sitting position for extended periods, to take showers rather than tub baths, avoid crossing the legs at the knees, and avoid driving for at least 4 weeks or until the surgeon has given permission to do so.