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The healthcare provider orders an IV solution of dextrose 5% in water at 100ml/hour. What would the flow rate be if the drop factor is 15 gtt = 1 ml?
- A. 5 gtt/minute
- B. 13 gtt/minute
- C. 25 gtt/minute
- D. 50 gtt/minute
Correct Answer: C
Rationale: To determine the flow rate in drops per minute, multiply the ordered volume per hour by the drop factor (100 ml/hour x 15 gtt/ml = 1500 gtt/hour). Then, divide the result by 60 minutes to convert it to drops per minute (1500 gtt/hour · 60 minutes = 25 gtt/minute). Therefore, the correct answer is 25 gtt/minute.
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A patient is kept off food and fluids for 10 hours before surgery. His oral temperature at 8 a.m. is 99.8°F (37.7°C). This temperature reading probably indicates:
- A. Infection
- B. Hypothermia
- C. Anxiety
- D. Dehydration
Correct Answer: D
Rationale: A patient being kept off food and fluids before surgery can lead to dehydration. Dehydration can cause a slight increase in body temperature, which could explain the elevated oral temperature reading of 99.8°F (37.7°C) in this scenario. Infections are more likely to cause higher fevers, hypothermia would present with a lower temperature, and anxiety typically does not directly affect body temperature in this manner.
The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. Nursing responsibilities for Mrs. Mitchell now include:
- A. Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time.
- B. Reporting an APTT above 45 seconds to the physician
- C. Assessing the patient for signs and symptoms of frank and occult bleeding
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D. When a physician orders a maintenance dose of subcutaneous heparin, nursing responsibilities include reviewing daily activated partial thromboplastin time (APTT) and prothrombin time to monitor the patient's coagulation status, reporting an APTT above 45 seconds to the physician as it may indicate a risk of bleeding, and assessing the patient for signs and symptoms of frank and occult bleeding, which are potential adverse effects of anticoagulant therapy. Therefore, all the options listed are essential nursing responsibilities when a patient is on subcutaneous heparin therapy.
Which of the following measures is not recommended to prevent pressure ulcers?
- A. Massaging the reddened area with lotion
- B. Using a water or air mattress
- C. Adhering to a schedule for positioning and turning
- D. Providing meticulous skin care
Correct Answer: A
Rationale: Massaging a reddened area can cause further tissue damage by increasing pressure on already compromised skin. The other options, such as using specialized mattresses, adhering to repositioning schedules, and maintaining good skin care, are all recommended strategies to prevent pressure ulcers by reducing pressure and friction on vulnerable areas of the skin.
How can preserving skin integrity impact the circular chain of infection?
- A. Host
- B. Reservoir
- C. Mode of transmission
- D. Portal of entry
Correct Answer: D
Rationale: Preserving skin integrity plays a key role in breaking the chain of infection by eliminating the portal of entry for pathogens. When the skin is intact, it acts as a natural barrier that prevents pathogens from entering the body. By maintaining skin integrity through proper hygiene and wound care, the risk of infection is significantly reduced, disrupting the cycle of infection transmission.
The physician orders 10 gr of aspirin for a patient. The equivalent dose in milligrams is:
- A. 0.6 mg
- B. 10 mg
- C. 60 mg
- D. 600 mg
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.