Nokea
The doctor has ordered 1,000 cc of intravenous fluid every 8 hours. You will be using intravenous tubing that delivers 20 cc/drop. At what rate will you adjust the intravenous fluid flow? _____ gtts per minute.
- A. 38 gtts/min
- B. 42 gtts/min
- C. 50 gtts/min
- D. 40 gtts/min
Correct Answer: D
Rationale: To calculate the rate: 1000 cc/8 hours = 125 cc/hour. 125 cc/hour * 1 drop/20 cc * 1 hour/60 minutes = 40 gtts/min. Therefore, the correct answer is 40 gtts/min. Choice A (38 gtts/min) is incorrect as it doesn't match the calculation result. Choice B (42 gtts/min) is incorrect as it is not the calculated rate. Choice C (50 gtts/min) is incorrect as it is not the calculated rate either.
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What is the role of a nurse in patient education?
- A. Providing patients with necessary information to manage their health
- B. Limiting information to prevent confusion
- C. Using complex medical terminology
- D. Discouraging questions from patients
Correct Answer: A
Rationale: The correct answer is A: Providing patients with necessary information to manage their health. Nurses play a crucial role in patient education by offering essential information to help patients understand and manage their health conditions. This empowers patients to make informed decisions about their health and improve their overall well-being. Choices B, C, and D are incorrect. Limiting information would hinder patient understanding and decision-making, using complex medical terminology can confuse patients, and discouraging questions goes against the essence of patient education.
A charge nurse making rounds observes that an assistive personnel (AP) has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first?
- A. Remove the restraints from the client's wrists
- B. Review the chart for nonrestraint alternatives for agitation
- C. Speak with the AP about the incident
- D. Inform the unit manager of the incident
Correct Answer: A
Rationale: The correct action for the nurse to take first is to remove the restraints from the client's wrists. Restraints should not be applied without a prescription due to the risk of harm to the client. Removing the restraints promptly is a priority to ensure the client's safety. Reviewing nonrestraint alternatives, speaking with the AP, and informing the unit manager can follow after ensuring the client's immediate safety by removing the restraints.
A nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.4 mEq/L. Which of the following would the nurse expect to note on the electrocardiogram as a result of the laboratory value?
- A. ST depression
- B. Inverted T wave
- C. Prominent U wave
- D. Tall peaked T waves
Correct Answer: D
Rationale: The correct answer is 'Tall peaked T waves.' Tall peaked T waves are characteristic ECG changes associated with hyperkalemia. In hyperkalemia, the elevated potassium levels affect the myocardium, leading to changes in the ECG. ST depression (Choice A) is more commonly associated with myocardial ischemia or infarction. Inverted T wave (Choice B) is seen in conditions like myocardial ischemia or CNS events. Prominent U wave (Choice C) is typically associated with hypokalemia or certain medications. Therefore, in this scenario, the nurse would expect to note tall peaked T waves on the electrocardiogram due to the elevated potassium level.
Which of the following best describes evidence-based practice?
- A. Using outdated research
- B. Relying on personal experience alone
- C. Integrating clinical expertise with the best available evidence
- D. Disregarding patient preferences
Correct Answer: C
Rationale: Evidence-based practice involves integrating clinical expertise with the best available evidence to make informed decisions about patient care. Choice A is incorrect as evidence-based practice relies on current and relevant research. Choice B is incorrect as it emphasizes the importance of not relying solely on personal experience. Choice D is incorrect as patient preferences play a significant role in evidence-based practice.
When developing an educational program for staff regarding a new intravenous pump, what is the correct sequence of actions for a nurse to take?
- A. Develop learning objectives for the program
- B. Identify what skills to teach the staff members
- C. Conduct program evaluation with staff members
- D. Schedule several sessions of the program
Correct Answer: B
Rationale: The correct sequence of actions when developing an educational program for staff regarding a new intravenous pump is to first identify what skills to teach the staff members. This step is essential as it sets the foundation for the learning objectives to be developed next. Once the learning objectives are established, scheduling several sessions of the program can be planned accordingly. Finally, after the program has been conducted, program evaluation with staff members should take place to assess the effectiveness of the educational program. Therefore, options A, C, and D are out of sequence, making them incorrect choices.