Nokea
An infusion of lidocaine hydrochloride (Xylocaine) is running at 30 mL/hour. The dilution is 1,000 mg/250 mL. What dosage is the client receiving per minute?
Correct Answer: 2 mg/minute.
Rationale: Calculate: 1,000 mg in 250 mL = 4 mg/mL. At 30 mL/hour, that's 30 mL × 4 mg/mL = 120 mg/hour. Per minute: 120 mg ÷ 60 min = 2 mg/minute.
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A 30-year-old client is hospitalized with a fractured femur, which is being treated with skeletal traction. He states that he has not had a bowel movement for 2 days. Which of the following interventions is most appropriate at this time?
- A. Administer a tap water enema.
- B. Place the client on the bedpan every 2 to 3 hours.
- C. Increase the client's fluid intake to 3,000 mL/day.
- D. Perform range-of-motion movements to all extremities.
Correct Answer: C
Rationale: Increasing fluid intake promotes bowel motility, addressing constipation in a client immobilized by traction.
The nurse is teaching a client with a new diagnosis of hypertension about lifestyle modifications. Which of the following instructions should be included? Select all that apply.
- A. Reduce sodium intake.
- B. Engage in regular aerobic exercise.
- C. Limit alcohol consumption.
- D. Quit smoking.
- E. Increase saturated fat intake.
Correct Answer: A, B, C, D
Rationale: Reducing sodium, exercising, limiting alcohol, and quitting smoking lower blood pressure. Saturated fats should be avoided.
As you are assessing the fetus during labor you are determining and the fetal lie, presentation, attitude, station and position. Your client asks you what all these assessments are. Among other things, how should you respond to the mother?
- A. You should explain that fetal lie is where the fetus' presenting part is within the birth canal during labor, among other information about the other assessments.
- B. You should explain that fetal presentation is the relationship of the fetus's spine to the mother's spine, among other information about the other assessments.
- C. You should explain that fetal attitude is the relationship of the fetus' presenting part to the anterior, posterior, right or left side of the mother's pelvis, among other information about the other assessments.
- D. You should explain that fetal station is the level of the fetus' presenting part in relationship to the mother's ischial spines, among other information about the other assessments.
Correct Answer: D
Rationale: Fetal station refers to the level of the fetus's presenting part relative to the mother's ischial spines, measured in centimeters above or below the spines. This is the correct definition among the options provided.
A male client has been diagnosed as having a low sperm count during infertility studies. After instructions by the nurse about some causes of low sperm counts, the nurse determines that the client needs further instructions when he says low sperm counts may be caused by which of the following?
- A. Varicocele.
- B. Frequent use of saunas.
- C. Endocrine imbalances.
- D. Decreased body temperature.
Correct Answer: D
Rationale: Decreased body temperature is not a cause of low sperm count; elevated temperatures, such as from saunas, can impair spermatogenesis, indicating a need for further teaching.
Which oral contraceptive is considered safe for use while breast-feeding because it will not affect the breast milk or breast-feeding?
- A. Estrogen.
- B. Estrogen and progestin.
- C. Progestin.
- D. Testosterone.
Correct Answer: C
Rationale: Progestin-only contraceptives are safe during breast-feeding, as they do not affect milk production.