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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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In preparation to administer an intermittent tube feeding, the nurse aspirates 40 mL of undigested formula from the client's nasogastric tube. Which intervention should the nurse implement as a result of this finding?
- A. Discard the aspirate and record as client output.
- B. Mix with new formula to administer the feeding.
- C. Dilute with water and inject into the nasogastric tube.
- D. Reinstill the aspirate through the nasogastric tube via gravity and syringe.
Correct Answer: D
Rationale: After checking residual feeding contents, the nurse reinstills the gastric contents into the stomach by removing the syringe bulb or plunger and pouring the gastric contents via the syringe into the nasogastric tube. Gastric contents should be reinstilled (unless they exceed an amount of 100 mL or as defined by agency policy) to maintain the client's fluid and electrolyte balance. The nurse avoids mixing gastric aspirate with fresh formula to prevent contamination. Because the gastric aspirate is a small volume, it should be reinstilled; however, mixing the formula with water can also disrupt the client's fluid and electrolyte balance unless the client is dehydrated.
A client prescribed prazosin hydrochloride asks the nurse why the first dose must be taken at bedtime. Which response by the nurse is based on the understanding of the first dose use of prazosin hydrochloride?
- A. Treatment with prazosin hydrochloride results in drowsiness.
- B. Treatment with prazosin hydrochloride can cause dependent edema.
- C. Prazosin hydrochloride should be taken when the stomach is empty.
- D. Treatment with prazosin hydrochloride can cause dizziness or possible syncope.
Correct Answer: D
Rationale: Prazosin is an alpha-adrenergic blocking agent. 'First-dose hypotensive reaction' may occur during early therapy, which is characterized by dizziness, lightheadedness, and possible loss of consciousness. The occurrence of these effects is better tolerated if the client is in bed. This also can occur when the dosage is increased. This effect usually disappears with continued use or the dosage is decreased.
What should the nurse consider when determining whether a client diagnosed with a respiratory disease could tolerate and benefit from active progressive relaxation? Select all that apply.
- A. Social status
- B. Financial status
- C. Functional status
- D. Medical diagnosis
- E. Ability to expend energy
- F. Motivation of the individual
Correct Answer: C,D,E,F
Rationale: Active progressive relaxation training teaches the client how to effectively rest and reduce tension in the body. Some important considerations when choosing the type of relaxation technique are the client's physiological and psychological status. Because active progressive relaxation training requires a moderate expenditure of energy, the nurse needs to consider the client's functional status, medical diagnosis, and ability to expend energy. For example, a client with advanced respiratory disease may not have sufficient energy reserves to participate in active progressive relaxation techniques. The client needs to be motivated to participate in this form of alternative therapy to obtain beneficial results. The client's social or financial status has no relationship with her or his ability to tolerate and benefit from active progressive relaxation.
The nurse is performing an assessment on a female client who is suspected of having mittelschmerz. Which subjective finding supports the possibility of this condition?
- A. Experiences pain during intercourse
- B. Has pain at the onset of menstruation
- C. Experiences profuse vaginal bleeding
- D. Has sharp pelvic pain during ovulation
Correct Answer: D
Rationale: Mittelschmerz (middle pain) refers to pelvic pain that occurs midway between menstrual periods or at the time of ovulation. The pain is caused by a growth follicle within the ovary, or rupture of the follicle and subsequent spillage of follicular fluid and blood into the peritoneal space. The pain is fairly sharp and is felt on the right or left side of the pelvis. It generally lasts 1 to 3 days, and slight vaginal bleeding may accompany the discomfort.
The nurse is reviewing the laboratory results for a client who is receiving torsemide 5 mg orally daily. What value should indicate to the nurse that the client might be experiencing an adverse effect of the medication?
- A. A chloride level of 98 mEq/L (98 mmol/L)
- B. A sodium level of 135 mEq/L (135 mmol/L)
- C. A potassium level of 3.1 mEq/L (3.1 mmol/L)
- D. A blood urea nitrogen (BUN) level of 15 mg/dL (5.4 mmol/L)
Correct Answer: C
Rationale: Torsemide is a loop diuretic. The medication can produce acute, profound water loss; volume and electrolyte depletion; dehydration; decreased blood volume; and circulatory collapse. Option 3 is the only option that indicates electrolyte depletion because the normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). The normal chloride level is 98 to 107 mEq/L (98 to 107 mmol/L). The normal sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). The normal BUN level ranges from 10 to 20 mg/dL (3.6 to 7.1 mmol/L).