How many drops per minute should be delivered?
- A. 6
- B. 17
- C. 50
- D. 100
Correct Answer: B
Rationale: The correct answer is B: 17 drops per minute. To calculate the correct drip rate, you need to use the formula: (Volume to be infused in mL / Time in minutes) x Drop factor. In this case, if the volume to be infused is 100 mL and the time is 60 minutes with a drop factor of 20, the calculation would be: (100 / 60) x 20 = 33.33 drops per minute. Since we cannot deliver fractional drops, the closest whole number is 17 drops per minute. This ensures the correct delivery rate for the medication.
Choice A (6 drops per minute) is incorrect as it would be too slow and may not deliver the medication effectively. Choice C (50 drops per minute) and Choice D (100 drops per minute) are incorrect as they would both deliver the medication too quickly, potentially causing harm to the patient. The correct answer, 17 drops per minute, ensures a safe and accurate delivery rate
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A pregnant client requires immediate but temporary protection from chickenpox. Which type of immunization would be required?
- A. Naturally acquired active immunization
- B. Artificially acquired passive
- C. Artificially acquired active immunization immunization
- D. Passive immunization
Correct Answer: D
Rationale: The correct answer is D: Passive immunization. This involves administering pre-formed antibodies to provide immediate protection. In the case of a pregnant client needing temporary protection from chickenpox, passive immunization is necessary as it offers immediate immunity without stimulating the client's immune system.
- A (Naturally acquired active immunization): This involves exposure to the pathogen and the body producing its antibodies, which takes time and is not suitable for immediate protection.
- B (Artificially acquired passive immunization): This option doesn't involve providing pre-formed antibodies, which are needed for immediate protection.
- C (Artificially acquired active immunization): This method requires time for the body to develop its immunity, not providing immediate protection as needed in this scenario.
A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data?
- A. The patient can now perform the dressing changes without help.
- B. The patient can begin retaking all of the previous medications.
- C. The patient is apprehensive about discharge.
- D. The patient’s surgery was not successful.
Correct Answer: C
Rationale: The correct answer is C because the patient expressing fear of going home and being alone indicates apprehension about discharge. This is supported by stable vital signs and nearly healed incision, suggesting physical recovery. Choice A is incorrect as fear of being alone does not necessarily mean the patient can perform dressing changes independently. Choice B is incorrect as resuming medications is not related to the patient's fear of being alone. Choice D is incorrect as there is no evidence to suggest the surgery was unsuccessful based on the information provided.
After cancer chemotherapy, a client experiences nausea and vomiting. The nurse should highest priority to which intervention?
- A. Serving small portions bland food
- B. Encouraging rhythmic breathing exercises
- C. Administering metoclopramide (Reglan) and dexamethasone (Decadron) as prescribed
- D. Withholding fluids for the first 4 to 6 hours after chemotherapy administration
Correct Answer: C
Rationale: The correct answer is C because administering antiemetic medications like metoclopramide and dexamethasone helps control nausea and vomiting post-chemotherapy. Metoclopramide acts on the gut to reduce nausea, while dexamethasone decreases inflammation and suppresses the vomiting reflex. Choice A focuses on dietary interventions but does not address the physiological cause of nausea. Choice B with breathing exercises may help some clients but does not directly address the nausea and vomiting. Choice D is incorrect as withholding fluids can lead to dehydration, which is not recommended after chemotherapy.
Which of the following is an early sign of anemia?
- A. Palpitations
- B. Pallor
- C. Glossitis
- D. Weight loss
Correct Answer: B
Rationale: The correct answer is B: Pallor. Pallor, which refers to paleness of the skin, is an early sign of anemia due to decreased red blood cell levels. Anemia causes reduced oxygen delivery to tissues, leading to paleness. Palpitations (A) may occur in anemia but are not an early sign. Glossitis (C) and weight loss (D) are not typically early signs of anemia and are more commonly associated with other health conditions.
The nurse is caring for a client who’s hypoglycemic. This client will have a blood glucose level:
- A. Below 70mg/dl
- B. Between 120 and 180mg/dl
- C. Between 70 and 120mg/dl
- D. Over 180mg/dl
Correct Answer: A
Rationale: The correct answer is A: Below 70mg/dl. Hypoglycemia is defined as a blood glucose level below 70mg/dl. Symptoms of hypoglycemia include confusion, shakiness, and sweating. Treating hypoglycemia involves administering fast-acting carbohydrates. Choices B, C, and D are incorrect because they describe blood glucose levels that are within the normal or hyperglycemic range, which are not indicative of hypoglycemia. It is essential for the nurse to recognize and promptly address hypoglycemia to prevent serious complications.