Nokea
What is the threshold of dextrose concentrations that can safely be administered through a peripheral IV?
- A. Dextrose concentrations below 20% can be safely administered through a peripheral IV; dextrose concentrations above 20% should not be administered through a peripheral IV.
- B. Dextrose concentrations below 5% can be safely administered through a peripheral IV; dextrose concentrations above 5% should not be administered through a peripheral IV.
- C. Dextrose concentrations below 10% can be safely administered through a peripheral IV; dextrose concentrations above 10% should not be administered through a peripheral IV.
- D. Dextrose concentrations above 5% can be safely administered through a peripheral IV; dextrose concentrations below 5% should not be administered through a peripheral IV.
Correct Answer: C
Rationale: Dextrose concentrations below 10% are considered safe for administration through a peripheral IV, as concentrations above this threshold can lead to phlebitis, causing inflammation of the vein. Concentrations above 10% should not be administered through a peripheral IV to prevent vein irritation. Choice A is incorrect because concentrations above 20% are too high for a peripheral IV. Choice B is incorrect as dextrose concentrations below 5% are too low to be effective. Choice D is incorrect because the statement is reversed, suggesting that concentrations above 5% are safe, which is not true.
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The client has an order for an IV piggyback of Ceftriaxone 750mg in 50mL D5W to run over 30 minutes. What is the appropriate drip rate?
- A. 100 mL/hr
- B. 150 mL/hr
- C. 200 mL/hr
- D. 50 mL/hr
Correct Answer: A
Rationale: To calculate the drip rate, you need to convert the time from minutes to hours. The formula is (Volume to be infused / Time for infusion in minutes) x (60 minutes / 1 hour). Substituting the values, (50 mL / 30 min) x (60 min / 1 hr) = 100 mL/hr. Therefore, the appropriate drip rate is 100 mL/hr. Choices B, C, and D are incorrect as they do not match the calculated drip rate. Option A, 100 mL/hr, is the correct drip rate for administering Ceftriaxone 750mg in 50mL D5W over 30 minutes.
Which reported symptom(s) would indicate a client with Addison's disease has received too much fludrocortisone (Florinef) replacement?
- A. Oily skin and hair
- B. Weight gain of 6 pounds in one week
- C. Loss of muscle mass in arms and legs
- D. Increased blood glucose level
Correct Answer: B
Rationale: Fludrocortisone replacement in Addison's disease involves mimicking the action of aldosterone, a mineralocorticoid that causes the retention of sodium and water. Excessive retention of sodium and water can lead to weight gain. Therefore, a sudden increase in weight, especially a significant amount like 6 pounds in one week, can indicate an overdose of fludrocortisone. Choices A, C, and D are incorrect because oily skin and hair, loss of muscle mass, and increased blood glucose levels are not typically associated with excessive fludrocortisone replacement.
When assessing a client with deep pitting edema, with the indentation remaining for a short time and visible leg swelling, how should a nurse document this finding?
- A. 1+ edema
- B. 2+ edema
- C. 3+ edema
- D. 4+ edema
Correct Answer: C
Rationale: The correct answer is 3+ edema. When assessing for edema, the nurse presses thumbs against the ankle malleolus or the tibia. If the skin retains an indentation, it indicates pitting edema. The grading scale for pitting edema includes: 1+ for mild pitting with slight indentation and no perceptible leg swelling, 2+ for moderate pitting where the indentation subsides rapidly, 3+ for deep pitting with an indentation remaining briefly and visible leg swelling, and 4+ for very deep pitting with a long-lasting indentation and significant leg swelling. Choices A, B, and D do not accurately represent the severity of the edema described in the scenario.
The nurse is caring for a client who has dysphagia related to a stroke. The nurse works with the client to explain what food and beverages might minimize aspiration. What is this an example of?
- A. Health promotion
- B. Secondary prevention
- C. Tertiary prevention
- D. Primary prevention
Correct Answer: B
Rationale: The nurse working with the client to explain what food and beverages might minimize aspiration is an example of secondary prevention. Secondary prevention involves early detection and intervention to prevent complications or worsening of a condition. In this case, the nurse is helping to prevent aspiration pneumonia by providing education and guidance on safe eating and drinking practices after the client has already experienced dysphagia due to a stroke.
Choice A, health promotion, focuses on empowering individuals to adopt healthy behaviors to improve overall well-being and prevent illness. It is more about promoting general health rather than specific interventions related to a particular condition like dysphagia.
Choice C, tertiary prevention, involves managing and rehabilitating a condition to prevent further complications or disabilities. In this scenario, the nurse is not yet addressing complications but rather actively preventing them.
Choice D, primary prevention, aims to prevent the onset of a disease or condition before it occurs. The client in this case already has dysphagia, so the focus is on preventing further complications, making it a secondary prevention intervention.
A client who is experiencing infertility says to the nurse, 'I feel I will be incomplete as a man/woman if I cannot have a child.' Which of the following nursing diagnoses is likely to be appropriate for this client?
- A. Risk for Self-Harm
- B. Body Image Disturbance
- C. Ineffective Role Performance
- D. Powerlessness
Correct Answer: B
Rationale: The correct answer is 'Body Image Disturbance.' The client's statement reflects concerns about self-identity and completeness related to infertility, indicating a disturbance in body image perception. 'Risk for Self-Harm' is not the best choice as there is no indication of immediate self-harm. 'Ineffective Role Performance' is less appropriate since the statement does not directly relate to a disruption in the parent's role. 'Powerlessness' could be considered if the client expressed feelings of powerlessness specifically related to the infertility issue.