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Following surgical repair of a fractured femur, a client's hemoglobin falls to 7.4 and the physician orders one unit of packed red blood cells (250 mL) to be administered over two hours with a drop factor of 10 drops/mL. What flow rate (drops per minute) is needed? Record by rounding to the nearest whole number.
Correct Answer: 21
Rationale: To calculate the flow rate: (Volume X Drop factor)/ Time in minutes. Volume is 250 mL, drop factor is 10 drops/mL, time is 2 hours = 120 minutes. Thus, (250 X 10)/ 120 = 2,500/ 120 ≈ 20.83, rounded to 21 drops/minute.
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The nurse is preparing to admit a client from the emergency department with tuberculosis. Which of the following should the nurse anticipate in caring for this client? Select all that apply.
- A. fall precautions
- B. droplet precautions
- C. airborne precautions
- D. standard precautions
- E. placement in a negative airflow room
- F. use of PPE, including an N95 mask or powered air purifying respirators (PAPRs)
Correct Answer: C, D, E, F
Rationale: Tuberculosis requires airborne precautions, standard precautions, negative airflow rooms, and N95/PAPR use due to respiratory transmission. Fall precautions are not specific, and droplet precautions are incorrect.
Which client is at greatest risk for a caesarean section due to cephalopelvic disproportion (CPD)?
- A. A 25-year-old gravida 2, para 1
- B. A 30-year-old gravida 3, para 2
- C. A 17-year-old gravida 1, para 0
- D. A 32-year-old gravida 1, para 0
Correct Answer: C
Rationale: A 17-year-old primigravida is at higher risk for CPD due to a potentially underdeveloped pelvis, increasing the likelihood of cesarean delivery.
The schizophrenic client has become disruptive and requires seclusion. Which staff member can institute seclusion?
- A. The security guard
- B. The registered nurse
- C. The licensed practical nurse
- D. The nursing assistant
Correct Answer: B
Rationale: An RN has the authority to initiate seclusion based on clinical judgment.
The best size cathlon for administration of a blood transfusion to a six year old is:
- A. 18 gauge
- B. 19 gauge
- C. 22 gauge
- D. 20 gauge
Correct Answer: D
Rationale: A 20-gauge catheter is appropriate for blood transfusion in a six-year-old, balancing flow rate and vessel size.
A new graduate nurse completes her first full shift with her preceptor. It was a long, overwhelming day and the new nurse takes a deep breath and says to herself, 'You can do this! Nursing will be a challenge but you are up for it and tomorrow is a new day.' This type of communication is
- A. intrapersonal.
- B. horizontal.
- C. interpersonal.
- D. vertical.
Correct Answer: A
Rationale: Intrapersonal communication is self-talk, as the nurse reflects and motivates herself.