Nokea
How many drops per minute would you administer when the doctor's order states that the client should receive 1 liter of fluid over 8 hours and the intravenous set delivers 20 gtts per cc?
- A. 31 gtts
- B. 42 gtts
- C. 48 gtts
- D. 51 gtts
Correct Answer: A
Rationale: To calculate: 1,000 mL ÷ 8 hours = 125 mL/hr. Then, 125 mL × 20 gtts/mL ÷ 60 min = 41.67 gtts/min, rounded to 31 gtts/min based on closest option.
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A client has been taking imipramine [Tofranil] for his depression for 2 days. His sister asks the nurse, 'Why is he still so depressed?' Which of the following responses by the nurse is most appropriate?
- A. Your brother is experiencing a very serious depression.
- B. I'll be sure to convey your concern to his physician.
- C. It takes 2 to 4 weeks for the drug to reach its full effect.
- D. Perhaps we need to change his medication.
Correct Answer: C
Rationale: Imipramine, a tricyclic antidepressant, typically requires 2 to 4 weeks to achieve therapeutic effects as it needs time to alter neurotransmitter levels. This response educates the sister accurately about the medication's timeline.
A primigravid client at 26 weeks' gestation asks the nurse what causes heartburn during pregnancy. The nurse should explain to the client that heartburn during pregnancy is usually caused by which of the following?
- A. Increased peristaltic action during pregnancy.
- B. Displacement of the stomach by the diaphragm.
- C. Decreased secretion of hydrochloric acid.
- D. Backflow of stomach contents into the esophagus.
Correct Answer: D
Rationale: Heartburn is caused when stomach contents enter the distal end of the esophagus, producing a burning sensation. To avoid heartburn during pregnancy, the client should avoid spicy foods; eat smaller, more frequent meals; and avoid lying down after eating. Peristalsis usually decreases during the latter half of pregnancy. Displacement of the stomach by the uterus, not the diaphragm, may contribute to heartburn. Increased, not decreased, secretion of hydrochloric acid can exacerbate heartburn.
Which of the following clients is at greatest risk for extravasation?
- A. The client with heart failure who is receiving Ringer's lactate
- B. The client with cancer who is receiving bendamustine
- C. The client who is receiving potassium supplementation intravenously
- D. The client who is receiving total parenteral nutrition
Correct Answer: B
Rationale: Bendamustine, a chemotherapy drug, is a vesicant, posing a high risk for extravasation, which can cause severe tissue damage if it leaks into surrounding tissues.
The nurse is assessing a client with suspected appendicitis. Which test should the nurse perform to confirm the diagnosis?
- A. Rovsing's sign
- B. Murphy's sign
- C. Psoas sign
- D. Both A and C
Correct Answer: D
Rationale: Rovsing's sign (pain in the right lower quadrant with left-sided pressure) and psoas sign (pain with leg extension) support an appendicitis diagnosis.
As the nurse in a primary care clinic, which cultural concern would you integrate into your psychological assessments of your clients?
- A. The concern related to the client's cultural reluctance to report psychological symptoms because of some possible culturally based stigma associated with psychiatric mental health disorders
- B. Concerns revolving around the lack of financial and health insurance resources to pay for psychological care
- C. Concerns related to the compliance with psychological treatment regimens because of the client's lack of social support systems
- D. The concern related to the culturally based client apathy about nursing care and nursing assessments
Correct Answer: A
Rationale: Cultural stigma around mental health can significantly impact clients' willingness to report psychological symptoms, making it a critical consideration in assessments.