Nokea
The client is to receive a 100-mL intravenous antibiotic over 30 minutes via an intravenous pump. At what rate should the nurse set the IV pump?
Correct Answer: 200 mL/hr
Rationale: To infuse 100 mL over 30 minutes, calculate the hourly rate: (100 mL / 30 min) × 60 min/hr = 200 mL/hr. The pump should be set to 200 mL/hr.
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The nurse should place the client in which position?
- A. Knee-chest (genupectoral) position
- B. Sitting in an orthopneic position
- C. Side-lying position with his neck flexed
- D. Prone position with the head turned to the left side
Correct Answer: C
Rationale: The side-lying position with the neck flexed facilitates access to the lumbar spine for a lumbar puncture and helps open the intervertebral spaces.
When the nurse describes the myelogram procedure to the client, which statement is most accurate?
- A. Part of the test involves a lumbar puncture.'
- B. You will be asked to change positions frequently.'
- C. Dye is instilled into a vein in your arm.'
- D. Light anesthesia is administered during the test.'
Correct Answer: A
Rationale: A myelogram involves a lumbar puncture to inject contrast dye into the spinal canal for imaging.
When preparing the client for the upcoming positron emission tomography (PET) scan, the nurse instructs the client to avoid which substances the day before the test? Select all that apply.
- A. Caffeine
- B. Shampoo
- C. Diuretics
- D. Shellfish
- E. Alcohol
- F. Tobacco
Correct Answer: A,E,F
Rationale: Caffeine, alcohol, and tobacco can affect cerebral metabolism and blood flow, potentially altering PET scan results.
Which assessment data indicate that the client with a traumatic brain injury (TBI) exhibiting decorticate posturing on admission is responding effectively to treatment?
- A. The client has flaccid paralysis.
- B. The client has purposeful movement.
- C. The client has decerebrate posturing with painful stimuli.
- D. The client does not move the extremities.
Correct Answer: B
Rationale: Purposeful movement (B) indicates improved brain function compared to decorticate posturing. Flaccid paralysis (A) or decerebrate posturing (C) suggest worsening, and no movement (D) is not an improvement.
The nurse caring for a client who has been abusing amphetamines writes a problem of 'cardiovascular compromise.' Which nursing interventions should be implemented?
- A. Monitor the telemetry and vital signs every four (4) hours.
- B. Encourage the client to verbalize the reason for using drugs.
- C. Provide a quiet, calm atmosphere for the client to rest.
- D. Place the client on bedrest and a low-sodium diet.
Correct Answer: A,C
Rationale: Amphetamine abuse can cause tachycardia and hypertension. Monitoring telemetry and vital signs (A) detects cardiovascular changes, and a calm atmosphere (C) reduces stimulation. Verbalizing reasons (B) is psychosocial, and bedrest/low-sodium diet (D) is not indicated.