hardest EAQs
A client is rescued from a house fire and arrives at the emergency department 1 hour after the rescue. The client weighs 132 pounds (60 kilograms) and is burned over 35% of the body. The nurse expects that the amount of lactated Ringer solution that will be prescribed to be infused in the next 8 hours is what? 1 2100 mL 2 4200 mL 3 6300 mL 4 8400 mL
2: In the first 8 hours 4200 mL should be infused. According to the Parkland (Baxter) formula, one half of the total daily amount of fluid should be administered in the first 8 hours. Because the client weighs 60 kg (132 pounds ÷ 2.2 kg = 60 kg), the calculation is 60 kg × 4 mL/kg × 35% burns = 8400 mL per day; half of this amount should be infused within the first 8 hours. 2100 mL, 6300 mL, and 8400 mL are incorrect calculations.
A client with metastatic melanoma is being treated with interferon gamma 1b. The nurse concludes that the teaching about this drug is understood when the client makes which statement? 1 "I will increase my fluid intake to several quarts (liters) every day." 2 "I need to discard any reconstituted solution at the end of the week." 3 "I can continue driving my car as before as long as I have the stamina." 4 "I should be able to continue my usual activity while taking this medication.
1: Increasing fluid intake to several quarts (liters) every day helps flush the kidneys and prevent nephrotoxicity, especially during the early phase of treatment. Reconstituted solution can be stored in the refrigerator for one month. Confusion, dizziness, and hallucinations are side effects of this drug; the client should avoid hazardous tasks, such as driving or using machinery. Activity may have to be altered because fatigue and other flulike symptoms are common with this drug
At 10 AM the nurse hangs a 1000-mL bag of D5W with 20 mEq of potassium chloride to be administered at 80 mL/hr. At noon the healthcare provider prescribes a stat infusion of an intravenous (IV) antibiotic of 100 mL to be administered via piggyback over 1 hour. How much longer than expected will it take the primary bag to empty if the nurse interrupts the primary infusion to use the circulatory access for the secondary infusion of the antibiotic? 1/4 hour 1/2 hour 3/4 hour 1 hour
1 hour; An infusion of 1000 mL at 80 mL should take 12.5 hours. Because the primary infusion is interrupted for an hour while the antibiotic is infused, the primary bag will run an hour longer than if it were running uninterrupted. One quarter, half, and three quarters of an hour are incorrect calculations
In what ways can a nurse promote medication adherence in children? Select all that apply. 1. By mixing oral medications with food or juice 2 By communicating with parents to ensure active participation 3 By selecting a convenient route of dosage and dosing schedule 4 By measuring liquid formulations with a calibrated spoon or syringe 5 By refraining from readministering the drug if the child spills it or spits it ou
1, 2, 3, 4: Oral medications may be mixed with food or fruit juice to improve their palatability. Communication with parents helps to ensures conscientious and skilled participation. The most convenient dosage form and dosing schedule should be selected to help ensure easy administration. Liquid formulations should be measured with the use of a calibrated spoon or syringe to help prevent inappropriate dosing. If the child spits out or spills the drug, the amount of drug spilled should be readministered.
A child is administered fentanyl to ease the pain of an injury. Upon regaining consciousness, the child wants to go home. What criteria must the child meet before being discharged from the hospital? Select all that apply. 1 The child is alert and active. 2 The child's pain is at baseline levels. 3 The child's body temperature is 102°F (38.9°C). 4 The child's vital signs have remained stable. 5 The child's oxygen saturation is 65% on room air
1,2,4: The child should be alert and oriented before being discharged. The child may be discharged if the pain has been reduced. The child's vital signs should be stable and consistent before the child is discharged. The child's body temperature should be below 101°F (38.3°C) before discharge. The child's oxygen saturation should be at least 95% on room air.
The client has clay-colored stools. The nurse should assess for clinical manifestations of an increase in which process? 1 Blood clotting 2 Fibrin formation 3 Prothrombin time 4 Calcium use
3: Clay-colored stools indicate the absence of bile in the intestine. Absorption of phytonadione, a fat-soluble vitamin, requires the action of bile. It is necessary for the formation of prothrombin (factor II); lack of phytonadione increases (prolongs) the prothrombin time/international normalized ratio (INR). Blood clotting will decrease. Fibrin formation will decrease. Calcium metabolism is not influenced by phytonadione.
A nurse anticipates that most clients with phobias will use which defense mechanisms? 1 Dissociation and denial 2 Introjection and sublimation 3 Projection and displacement 4 Substitution and reaction formation
3: Clients with phobias cope with anxiety by placing it on specific persons, objects, or situations through displacement, projection, or both. The person with a phobia recognizes and admits the exaggerated fear as a real part of the self and does not deny it. Neither introjection, whereby a person internalizes and incorporates the traits of another, nor sublimation, whereby socially acceptable behavior is substituted for unacceptable instincts, is related to phobic activity. A less valued object is not substituted for one more highly valued (substitution), nor are the expressed feelings opposite of the experienced feelings of fear (reaction formation).
A nurse is caring for a client who had surgery for a biliary complication and now has a T-tube in place. The nurse explains that the T-tube was placed for what reason? 1 Divert the bile flow to the cystic duct 2 Drain serosanguineous fluid from the operative site 3 Help bile drain while the common bile duct is edematous 4 Prevent postoperative infection at the site of the incision
3: The inflammatory response occurs because of the trauma of surgery; the T-tube maintains patency of the common bile duct until edema subsides. A T-tube diverts the bile out of the body into a collection bag. Draining serosanguineous fluid from the operative site is the purpose of a portable wound drainage system, not a T-tube. Surgical asepsis prevents infection at the site of the incision; the T-tube is a portal of entry for microorganisms and places the client at risk for infection.
A healthcare provider prescribes ophthalmic drops for a client. What should a nurse include in the instructions for a client learning to self-administer eyedrops? 1 Lie on the unaffected side for administration. 2 Instill drops onto the pupil to promote absorption. 3 Close eyes tightly after administering the eyedrops. 4 Apply pressure to the nasolacrimal duct after instillation.
4) Applying pressure prevents absorption into the duct, which may lead to systemic effects. Lying on the unaffected side is indicated for ear drops. Tilting the head back and looking up facilitate the instillation of eyedrops. Eyedrops should be instilled into the conjunctival sac, not onto the pupil. Closing the eyes tightly will force drops out of the eye.
A nurse is assessing a client with Crohn disease who is to have an upper gastrointestinal series. Which condition necessitates the cancellation of the upper gastrointestinal series? 1 Hemorrhoids 2 Hyperkalemia 3 Inflamed colon 4 Colon perforation
4: When a client has a perforated viscera, barium can leak out of the intestinal tract and cause inflammation or an abscess. Although hemorrhoids may be irritating, they do not contraindicate barium studies. Serum potassium is unaffected; barium is insoluble and will not affect blood content. Barium studies are not contraindicated when the bowel is inflamed. An upper gastrointestinal series is useful in diagnosing ulcerative colitis and Crohn disease.
