Nokea
The nurse has an order to give 1,000 mL of 0.9% NS with 20 meQ of potassium chloride over 8 hours. The IV set has a drop factor of 15. How many gtts/min should the client receive?
Correct Answer: 31
Rationale: Rate = 1,000 mL ÷ 8 hr = 125 mL/hr. Drops/min = (125 mL/hr × 15 gtts/mL) ÷ 60 min = 31.25 gtts/min, rounded to 31 gtts/min.
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A client with $B$ positive blood is scheduled for a transfusion of whole blood. Which finding requires nursing intervention?
- A. The available blood has been banked for 2 weeks.
- B. The blood available for transfusion is Rh negative.
- C. The client has a peripheral IV of D5 $1 / 2$ normal saline.
- D. The blood available for transfusion is type 0 positive.
Correct Answer: B
Rationale: Transfusing Rh-negative blood to an Rh-positive client can cause incompatibility reactions, requiring intervention to ensure Rh compatibility.
A client in labor has an order for Demerol (meperidine) 75 mg. IM to be administered 10 minutes before delivery. The nurse should:
- A. Wait until the client is placed on the delivery table and administer the medication
- B. Question the order
- C. Give the medication IM during the delivery to prevent pain from the episiotomy
- D. Give the medication as ordered
Correct Answer: B
Rationale: Administering meperidine 10 minutes before delivery risks neonatal respiratory depression, so the nurse should question the order.
The nurse is doing hourly rounds when he finds a 73-year-old female client unconscious on the floor next to the bed. An incident report must be filled out. What is the best statement for the nurse to write on the incident report?
- A. Client fell out of bed at some point between 0700 and 0800.'
- B. Client was found unresponsive on floor next to the bed.'
- C. Client likely slipped on the floor and hit her head.'
- D. Client attempted to ambulate without assistance and fell.'
Correct Answer: B
Rationale: The incident report should state objective findings: 'Client was found unresponsive on floor next to the bed.' Speculative statements (slipped, attempted to ambulate) are inappropriate.
The nurse administers a dose of acetaminophen to the wrong client. Which of the following actions is the most appropriate after notifying the physician?
- A. Notify her supervisor and complete an incident report.
- B. Ask the physician for an order of acetaminophen to cover the inadvertent administration.
- C. Take no further action because acetaminophen is relatively benign.
- D. Document in the client's record that an error in drug administration occurred.
Correct Answer: A
Rationale: Medication errors require notifying the supervisor and completing an incident report (A) to ensure proper follow-up and system improvements. Retroactively obtaining an order (B) is unethical, assuming acetaminophen is benign (C) is unsafe, and documenting the error in the client's record (D) is inappropriate.
The nurse is teaching a client on the proper technique to use an inhaler with a spacer for asthma management. Which action by the client would require intervention by the nurse?
- A. The client shakes the unit vigorously 3 or 4 times.
- B. The client places the inhaler over his tongue and seals his lips tightly around it.
- C. The client administers the next puff immediately after exhaling.
- D. The client keeps his lips closed and holds his breath for at least 10 seconds before exhaling.
Correct Answer: B
Rationale: Placing the inhaler over the tongue obstructs the airway; lips should seal around the mouthpiece with the tongue underneath. Other actions are correct.