Nokea
Which of these findings indicate that a pump to deliver a basal rate of 10 ml per hour plus PRN for pain breakthrough for a morphine drip is not working?
- A. The client complains of discomfort at the IV insertion site
- B. The client states 'I just can't get relief from my pain.'
- C. The level of the drug is 100 ml at 8 AM and is 80 ml at noon
- D. The level of the drug is 100 ml at 8 AM and is 50 ml at noon
Correct Answer: C
Rationale: The correct answer is that the level of the drug is 100 ml at 8 AM and is 80 ml at noon. With a basal rate of 10 mL per hour, a total of 40 mL should have been infused by noon, leaving only 60 mL in the container. Any amount greater than 60 mL at noon indicates that the pump is not functioning properly. Therefore, the finding of 80 mL at noon suggests the pump is not delivering the expected medication volume. Choices A and B are related to the client's symptoms and may indicate the need for pain management assessment but do not specifically indicate pump malfunction. Choice D, where the level drops to 50 mL at noon, would actually indicate that the pump is working effectively, as the expected volume has been delivered.
You may also like to solve these questions
Septic, anaphylactic, and neurogenic shock are all categorized as:
- A. Hypovolemic shock
- B. Cardiogenic shock
- C. Distributive shock
- D. Obstructive shock
Correct Answer: C
Rationale: Septic, anaphylactic, and neurogenic shock are all types of distributive shock. Distributive shock is characterized by a decrease in systemic vascular resistance, leading to poor tissue perfusion. Septic shock is caused by severe infection, anaphylactic shock is an extreme allergic reaction, and neurogenic shock results from damage to the nervous system. Hypovolemic shock (Choice A) is characterized by a decrease in intravascular volume, cardiogenic shock (Choice B) is due to heart failure, and obstructive shock (Choice D) results from obstruction of blood flow. Therefore, the correct categorization for septic, anaphylactic, and neurogenic shock is distributive shock.
During an intake screening for a patient with hypertension who has been taking ramipril for 4 weeks, which statement made by the patient would be most important for the nurse to pass on to the physician?
- A. ''I get dizzy when I get out of bed.''
- B. ''I'm urinating much more than I used to.''
- C. ''I've been running on the treadmill for 10 minutes each day.''
- D. ''I can't get rid of this cough.''
Correct Answer: D
Rationale: The correct answer is ''I can't get rid of this cough.'' Ramipril, an ACE inhibitor, commonly causes a persistent, dry cough as an adverse effect. This symptom can be indicative of bradykinin accumulation caused by ACE inhibitors. It is important for the nurse to inform the physician about this side effect so that a medication change to another class of antihypertensives, such as an ARB, may be considered. Choices A, B, and C are not directly related to the common adverse effects of ramipril and are not as concerning for a patient on this medication.
When is cleft palate repair usually performed in children?
- A. A cleft palate cannot be repaired in children.
- B. Repair is usually performed by age 8 weeks.
- C. Repair is usually performed by 2 months of age.
- D. Repair is usually performed between 6 months and 2 years.
Correct Answer: D
Rationale: Cleft palate repair timing is individualized based on the severity of the deformity and the child's size. Typically, cleft palate repair is performed between 6 months and 2 years of age. This age range allows for optimal outcomes and is often done before 12 months to promote normal speech development. Early closure of the cleft palate helps to facilitate speech development. Options A, B, and C are incorrect because a cleft palate can be repaired in children, and repair is usually performed between 6 months and 2 years of age, not at 8 weeks or 2 months.
The nurse is writing out discharge instructions for the parents of a child diagnosed with celiac disease. The nurse should focus primarily on which aspect of care?
- A. Restricting activity
- B. Following a gluten-free diet
- C. Following a lactose-free diet
- D. Giving medication to manage the condition
Correct Answer: B
Rationale: The primary nursing consideration in the care of a child with celiac disease is to instruct the child and parents about proper dietary management. The cornerstone of managing celiac disease is maintaining a strict gluten-free diet to prevent symptoms and long-term complications. While medications may be part of the treatment plan, dietary adjustments, particularly following a gluten-free diet, are crucial for managing the condition effectively. Restricting activity is not the primary focus of care for celiac disease. A lactose-free diet is not typically necessary unless the child also has lactose intolerance, which is distinct from celiac disease.
The parents of a newborn with a cleft lip are concerned and ask the nurse when the lip will be repaired. With which statement should the nurse respond?
- A. Cleft lip cannot be repaired.
- B. Cleft-lip repair is usually performed by 6 months of age.
- C. Cleft-lip repair is usually performed during the first months of life.
- D. Cleft-lip repair is usually performed between 6 months and 2 years.
Correct Answer: C
Rationale: Cleft-lip repair is typically performed during the first few months of life to address functional and cosmetic concerns at an early stage. Early repair can enhance bonding and facilitate feeding. While revisions may be necessary later on, addressing the cleft lip early is essential. Option A is incorrect as cleft lip repair is a common surgical procedure. Option B is incorrect as repair is typically done earlier than 6 months for better outcomes. Option D is incorrect as the usual timing for repair is within the first months of life, not between 6 months and 2 years.