Nokea
The healthcare professional prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The infusion set delivers 10 drops per milliliter. The healthcare professional should regulate the IV to administer approximately how many drops per minute?
- A. 80
- B. 8
- C. 21
- D. 25
Correct Answer: C
Rationale: To calculate the drops per minute for the IV infusion, first determine the total drops to be infused over 8 hours. 1,000 ml to be infused over 8 hours means 125 ml per hour (1000 ml / 8 hours = 125 ml/hr). Since the infusion set delivers 10 drops per ml, 125 ml/hr x 10 drops/ml = 1250 drops/hr. To find drops per minute, divide the drops per hour by 60 (minutes in an hour): 1250 drops/hr / 60 minutes = 20.83 drops/minute, which rounds up to 21 drops per minute (Option C). This rate ensures the correct infusion rate over 8 hours. Choices A, B, and D are incorrect calculations and do not provide the appropriate infusion rate needed to administer the IV over the specified time period.
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When assessing a client's heart sounds, the nurse hears a scratching sound during both systole and diastole. These sounds become more distinct when the nurse has the client sit up and lean forward. The nurse should document the presence of a:
- A. Pericardial friction rub
- B. Heart murmur
- C. S3 heart sound
- D. S4 heart sound
Correct Answer: A
Rationale: A pericardial friction rub is characterized by a scratching sound that occurs during both systole and diastole. It becomes more distinct when the client is sitting up and leaning forward. This indicates an inflammation of the pericardial sac rubbing against the layers of the heart. Heart murmurs (choice B) are abnormal heart sounds caused by turbulent blood flow, not by friction like in a pericardial rub. S3 and S4 heart sounds (choices C and D) are additional heart sounds related to abnormal ventricular filling, not to pericardial friction rubs.
A client is scheduled for an appendectomy and has given informed consent. Which statement by the client should the nurse address first preoperatively?
- A. "I am afraid to walk if it hurts too much."
- B. "I don't understand why I need this surgery."
- C. "I don't want my family helping me after the surgery."
- D. "I am afraid the scar will make me look disfigured."
Correct Answer: B
Rationale: The nurse should address the client's lack of understanding regarding the need for surgery first. Ensuring that the client comprehends the rationale for the procedure is essential for informed consent. Choices A, C, and D, while important, do not directly impact the client's understanding of the necessity of the surgery and can be addressed after clarifying the reason for the procedure.
A client with iron-deficiency anemia asks a nurse why the Z-track method is necessary for administering iron dextran. Which response should the nurse provide?
- A. It decreases the risk of injecting medication into a blood vessel.
- B. It delays medication absorption.
- C. It minimizes tissue irritation.
- D. It accelerates medication excretion.
Correct Answer: C
Rationale: The Z-track method is used to minimize tissue irritation by sealing the medication in the muscle. This technique helps prevent leakage of the medication into subcutaneous tissue, reducing the risk of irritation and staining at the injection site. Option A about decreasing the risk of injecting medication into a blood vessel is not correct as the primary purpose of the Z-track method is to prevent tissue irritation. Option B stating it delays medication absorption is incorrect as the Z-track method does not affect the rate of medication absorption. Option D mentioning it accelerates medication excretion is incorrect as the Z-track method does not impact medication excretion but rather focuses on minimizing tissue irritation.
A client with a new diagnosis of diabetes mellitus is being taught how to administer insulin. Which of the following instructions should the nurse include?
- A. Administer the insulin in the same body area each time.
- B. Store the insulin according to the manufacturer's instructions.
- C. Rotate injection sites within the same body area.
- D. Inject the insulin at a 45-degree angle.
Correct Answer: C
Rationale: The correct instruction the nurse should include is to rotate injection sites within the same body area. This practice helps prevent lipodystrophy, a condition characterized by the thickening or thinning of subcutaneous fat at the injection sites, which can affect insulin absorption. Choice A is incorrect because administering insulin in the same area each time can lead to lipodystrophy. Choice B is incorrect as insulin should be stored according to the manufacturer's instructions, which may include refrigeration. Choice D is incorrect because the angle of insulin injection (usually 90 degrees) is determined by the length of the needle and the amount of subcutaneous fat, not a fixed 45-degree angle.
A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the LPN/LVN implement?
- A. Give an around-the-clock schedule for administration of analgesics.
- B. Administer analgesic medication as needed when the pain is severe.
- C. Provide medication to keep the client sedated and unaware of stimuli.
- D. Offer a medication-free period to allow the client to engage in daily activities.
Correct Answer: A
Rationale: The correct action for the LPN/LVN to implement is to give an around-the-clock schedule for administration of analgesics. This approach helps maintain consistent pain management by providing the medication regularly, preventing the pain from becoming severe. Choice B is incorrect because waiting for severe pain before administering the analgesic may lead to uncontrolled pain levels. Choice C is inappropriate as the goal of pain management in hospice care is to provide comfort without unnecessary sedation. Choice D is also incorrect as offering a medication-free period may result in inadequate pain control for the client.