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A child is receiving maintenance intravenous (IV) fluids at the rate of 1000 mL for the first 10 kg of body weight, plus 50 mL/kg per day for each kilogram between 10 and 20. How many milliliters per hour should the nurse program the infusion pump for a child who weighs 19.5 kg?
- A. 24
- B. 61
- C. 73
- D. 58
Correct Answer: B
Rationale: To calculate the IV fluids for a 19.5 kg child:
1. For the first 10 kg: 1000 mL
2. For the weight between 10-20 kg: (19.5 kg - 10 kg) * 50 mL/kg = 475 mL
Total IV fluids = 1000 mL + 475 mL = 1475 mL
To convert to mL per hour: 1475 mL / 24 hours = ~61 mL/hr
Therefore, the correct answer is B (61 mL/hr).
Incorrect Choices:
A (24 mL/hr): Incorrect, as it doesn't consider the additional fluids for the weight between 10-20 kg.
C (73 mL/hr) and D (58 mL/hr): Incorrect, as these values are not obtained from the correct calculation based on the given formula.
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A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the emergency department (ED). The nurse determines that discharge teaching has been effective when the patient makes which statement?
- A. I will take salt tablets when I work outdoors in the summer.
- B. I should take acetaminophen (Tylenol) if I start to feel too warm.
- C. I should drink sports drinks when working outside in hot weather.
- D. I will move to a cool environment if I notice that I am feeling confused.
Correct Answer: C
Rationale: The correct answer is C: "I should drink sports drinks when working outside in hot weather." This statement is correct because hypotension and elevated temperature could indicate dehydration and electrolyte imbalance due to excessive sweating in hot weather. Drinking sports drinks can help replenish electrolytes lost through sweating and prevent dehydration.
Incorrect choices:
A: Taking salt tablets can lead to an imbalance in electrolytes and worsen the condition.
B: Acetaminophen can lower fever but does not address dehydration or electrolyte imbalance.
D: Moving to a cool environment when feeling confused is important but does not address the underlying issue of dehydration and electrolyte imbalance.
The nurse is caring for a patient with a subarachnoid hemorrhage who is intubated and placed on a mechanical ventilator with 10 cm H2O of peak end-expiratory pressure (PEEP). When monitoring the patient, the nurse will need to notify the healthcare provider immediately if the patient develops:
- A. Oxygen saturation of 93%.
- B. Respirations of 20 breaths/minute.
- C. Green nasogastric tube drainage.
- D. Increased jugular venous distention.
Correct Answer: D
Rationale: The correct answer is D: Increased jugular venous distention. In a patient with a subarachnoid hemorrhage and on mechanical ventilation, increased jugular venous distention can indicate increased intracranial pressure, which can be life-threatening. The nurse should notify the healthcare provider immediately as it may require urgent intervention to prevent further neurological deterioration.
A: Oxygen saturation of 93% is within the acceptable range for a patient on mechanical ventilation and may not require immediate notification.
B: Respirations of 20 breaths/minute are within normal limits for a ventilated patient and do not necessarily indicate a critical condition.
C: Green nasogastric tube drainage may indicate the presence of bile and could be related to gastrointestinal issues, but it does not pose an immediate threat to the patient's neurological status.
Following insertion of a pulmonary artery catheter (PAC),a bthirbe. cpohmy/tessitc ian orders the nurse to obtain a blood sample for mixed venous oxygen saturation (SvO ). Which action by the nurse best ensures the obtained value is accurate?
- A. Zero referencing the transducer at the level of the phlebostatic axis following insertion WWWWWW ..TTHHEENNUURRSSIINNGGMMAASSTTEERRYY..CCOOMM
- B. Calibrating the system with a central venous blood sample and arterial blood gas value
- C. Ensuring patency of the catheter using a 0.9% normal asbailrbin.ceo ms/otelsut tion pressurized at 300 mm Hg
- D. Using noncompliant pressure tubing that is no longer t han 36 to 48 inches and has minimal stopcocks
Correct Answer: B
Rationale: The correct answer is B because calibrating the system with central venous and arterial blood samples ensures accuracy of the mixed venous oxygen saturation (SvO2) measurement. This calibration allows for comparison of the values obtained from both sources to confirm the accuracy of the measurement.
Choice A is incorrect because zero referencing the transducer at the level of the phlebostatic axis does not directly address the accuracy of the SvO2 measurement.
Choice C is incorrect because ensuring patency of the catheter using normal saline pressurized at 300 mm Hg does not directly impact the accuracy of the SvO2 measurement.
Choice D is incorrect because using noncompliant pressure tubing does not ensure the accuracy of the SvO2 measurement. The length of the tubing and the presence of stopcocks are not directly related to obtaining an accurate SvO2 value.
A patient is admitted to the emergency department (ED) after falling through the ice while ice skating. Which assessment will the nurse obtain first?
- A. Heart rate.
- B. Breath sounds.
- C. Body temperature.
- D. Level of consciousness.
Correct Answer: C
Rationale: The correct answer is C: Body temperature. In a patient who has fallen through the ice, hypothermia is a major concern due to exposure to cold water. Assessing body temperature first is crucial to determine the severity of hypothermia and guide immediate interventions. Heart rate, breath sounds, and level of consciousness can be affected by hypothermia but are secondary assessments. Assessing body temperature is the priority to address the most life-threatening issue first.
What risk is the rationale for the recommendation of endot racheal rather than nasotracheal intubation?
- A. Basilar skull fracture
- B. Cervical hyperextension
- C. Impaired ability to "mouth" words
- D. Sinusitis and infection
Correct Answer: A
Rationale: The correct answer is A: Basilar skull fracture. Endotracheal intubation is recommended over nasotracheal intubation to avoid the risk of further damaging a basilar skull fracture. Nasotracheal intubation can potentially cause further injury due to the passage of the tube through the nasal cavity, which could exacerbate a basilar skull fracture.
Summary of other choices:
B: Cervical hyperextension - Not directly related to the choice between endotracheal and nasotracheal intubation.
C: Impaired ability to "mouth" words - Not a significant factor in determining the choice of intubation method.
D: Sinusitis and infection - While nasotracheal intubation can potentially lead to sinusitis and infection, the primary concern in this scenario is the risk of aggravating a basilar skull fracture.