Nokea
The healthcare provider prescribes an IV solution of regular insulin (Hummulin-R) 100 units in 250 ml of 0.45% saline to infuse at 12 units/hour. The nurse should program the infusion pump to deliver how many ml/hour?
- A. 30
- B. 3
- C. 40
- D. 15
Correct Answer: A
Rationale: To calculate the infusion rate in ml/hour, the nurse needs to divide the prescribed units per hour by the concentration of insulin. 12 units/hour ÷ (100 units/250 ml) = 30 ml/hour.
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A child of 36 months would be expected to:
- A. Build a tower of 5 cubes
- B. Repeat back 5 digits
- C. Draw a man with a head and body
- D. Demonstrate symbolic play
Correct Answer: D
Rationale: At 36 months, a child is expected to demonstrate symbolic play. Building a tower of 5 cubes and drawing a man with a head and body are also typical milestones.
A client who has a history of hypothyroidism was initially admitted with lethargy and confusion. Which additional finding warrants the most immediate action by the nurse?
- A. Facial puffiness and periorbital edema
- B. Hematocrit of 30%
- C. Cold and dry skin
- D. Further decline in level of consciousness
Correct Answer: D
Rationale: A further decline in level of consciousness could indicate myxedema coma, a life-threatening complication of hypothyroidism.
The nurse is assessing a child after a cardiac catheterization. Which complication should the nurse be assessing for?
- A. Cardiac arrhythmia
- B. Hypostatic pneumonia
- C. Heart failure
- D. Rapidly increasing blood pressure
Correct Answer: A
Rationale: Because a catheter is introduced into the heart, a risk exists of catheter-induced dysrhythmias occurring during the procedure. These are usually transient. Hypostatic pneumonia, heart failure, and rapidly increasing blood pressure are not risks usually associated with cardiac catheterization.
Which occurs in septic shock?
- A. Hypothermia
- B. Increased cardiac output
- C. Vasoconstriction
- D. Angioneurotic edema
Correct Answer: B
Rationale: Increased cardiac output, which results in warm, flushed skin, is one of the manifestations of septic shock. Fever and chills are characteristic of septic shock. Vasodilation is more common than vasoconstriction. Angioneurotic edema occurs as a manifestation in anaphylactic shock.
Guillain-Barre syndrome (GBS) is excluded by:
- A. A normal CSF
- B. The presence of autonomic neuropathy
- C. Distinct sensory level
- D. Ophthalmoplegia
Correct Answer: C
Rationale: A distinct sensory level is not a feature of GBS, which typically presents with ascending symmetrical weakness and absent reflexes.