Nokea
The nurse is hanging 1,000 mL of IV fluids to run for eight (8) hours. The intravenous tubing is a microdrip. How many gtt/min should the IV rate be set?
Correct Answer: 15
Rationale: Microdrip is 60 gtt/mL. Rate: (1,000 mL / 8 hr) x (60 gtt/mL / 60 min) = 125 mL/hr x 1 gtt/min = 15.625 gtt/min, rounded to 15 gtt/min.
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An adult has angina and is to be discharged on transdermal nitroglycerin. Which statement by the client indicates that the client needs additional teaching?
- A. I am glad that I can continue walking.
- B. I will change the site each day.
- C. I will be able to continue to drink alcoholic beverages.
- D. I will need to get up slowly.
Correct Answer: C
Rationale: Alcohol can enhance nitroglycerin’s hypotensive effects, increasing the risk of dizziness or fainting, requiring avoidance.
The client is complaining of nausea, and the nurse administers the antiemetic promethazine (Phenergan), IVP. Which intervention has priority for this client after administering this medication?
- A. Instruct the client to call the nurse before getting out of bed.
- B. Evaluate the effectiveness of the medication.
- C. Assess the client's abdomen and bowel sounds.
- D. Tell the client not to eat or drink for at least one (1) hour.
Correct Answer: A
Rationale: Promethazine causes sedation and orthostatic hypotension; instructing to call before ambulating prevents falls, the priority post-IVP.
The client has the following arterial blood gases: pH 7.19, Paco2 33, Pao2 95, and HCO3 19. Which medication would the nurse prepare to administer based on the results?
- A. Intravenous sodium bicarbonate.
- B. Oxygen via nasal cannula.
- C. Epinephrine intravenous push.
- D. Magnesium hydroxide orally.
Correct Answer: A
Rationale: Metabolic acidosis (low pH, low HCO3) requires sodium bicarbonate to correct pH. Oxygen, epinephrine, or antacids are inappropriate.
Aluminum hydroxide gel (Amphojel) is ordered for an adult who has acute renal failure. What is the primary reason for administering this drug to this client?
- A. To prevent the development of Curling's ulcers
- B. To bind phosphates
- C. To maintain normal pH
- D. To prevent diarrhea
Correct Answer: B
Rationale: In renal failure, aluminum hydroxide binds phosphates in the gut, reducing hyperphosphatemia, a common complication.
The client diagnosed with essential hypertension calls the clinic and tells the nurse she needs something for the flu. Which information should the nurse tell the client?
- A. OTC medications for the flu should not be taken because of your hypertension.
- B. If OTC medications do not relieve symptoms within three (3) days, contact the HCP.
- C. Tell the client to ask the pharmacist to recommend an OTC medication for the flu.
- D. Make an appointment for the client to receive the influenza vaccine.
Correct Answer: B
Rationale: OTC flu medications (e.g., decongestants) may raise BP but can be used cautiously; persistent symptoms warrant HCP contact. Total avoidance, pharmacist reliance, or vaccines are less appropriate.