Physiological Aspects of Care

An intravenous (IV) solution of 1000 mL 5% dextrose in water is to be infused at 125 mL/hr to correct a client's fluid imbalance. The infusion set delivers 15 drops/mL. To ensure that the solution will infuse over an eight-hour period, at how many drops per minute should the nurse set the rate of flow? Record the answer using a whole number. ______ gtts/min

1000 mL x 15/8 x 60 = 15,000/480 = 31.25 = 31 gtts/min

A client's serum potassium level has increased to 5.8 mEq/L. What action should the nurse implement first? 1.Call the laboratory to repeat the test. 2.Take vital signs and notify the charge nurse or health care provider. 3.Inform the cardiac arrest team to place them on alert. 4.Take an electrocardiogram and have lidocaine available

2.Take vital signs and notify the charge nurse or health care provider.

A client with Addison's disease is receiving cortisone therapy. The nurse expects what clinical indicators if the client abruptly stops the medication? (Select all that apply.) 1.Diplopia 2.Dysphagia 3.Tachypnea 4.Bradycardia 5.Hypotension

3.Tachypnea 5.Hypotension

A client presents with a severe stiff neck, shuffling gate, and other extrapyramidal symptoms. Benztropine 2.5 mg by mouth is prescribed. The medication is available in 1-mg scored tablets. How many tablets should the nurse administer? Record the answer using one decimal place. _________ tablets

Have 1 mg 1 tablets 1x = 1 × 2.5 x = 2.5 ÷ 1 x = 2.5 tablets

A prescription is written for famotidine (Pepcid) 20 mg intravenous piggyback (IVPB) every 12 hours. The vial is labeled 10 mg/1 mL. How many milliliters should the nurse administer? Record the answer using a whole number. _______ mL

Have 10 mg 1 mL 10x = 20 x = 20 ÷ 10 x = 2 mL

The physician orders 7,500 units erythropoietin (Procrit) to be administered subcutaneously weekly. The vial reads 10,000 units per milliliter. How much erythropoietin will the nurse give for each weekly dose? Include a leading zero if applicable. Record your answer using two decimal places. _____ mL

The nurse solves the problem as follows: 10,000 units/7,500 units = 1 mL/X 10,000 X = 7,500 X = 7,500/10,000 X=0.75 mL

A client is to receive 2000 mL of intravenous (IV) fluid in 12 hours. At what rate should the nurse set the electronic infusion control device? Record the answer using a whole number. ______ mL/hr

2000 ÷ 12 = 166.66. Round this to a whole number 167

A nurse is evaluating the effectiveness of treatment for a client with excessive fluid volume. What clinical finding indicates that treatment has been successful? 1.Clear breath sounds 2.Positive pedal pulses 3.Normal potassium level 4.Increased urine specific gravity

1.Clear breath sounds

A health care provider prescribes 250 mg of a medication. The vial reads 500 mg/mL. How much medication (mL) should the nurse administer? Include a leading zero if applicable. Record your answer using one decimal place. _____ mL

250 mg/X=500 mg/1 mL 500x=250 X=1/2 mL OR 0.5

A client's chest tube has accidentally dislodged. What is the nursing action of highest priority? 1.Place the client in a left side-lying position. 2.Apply oxygen via non-rebreather mask. 3.Apply a petroleum gauze dressing over the site. 4.Prepare to reinsert a new chest tube

3.Apply a petroleum gauze dressing over the site.

A child is to receive 60 mg of phenytoin (Dilantin). The medication is available as an oral suspension that contains 125 mg/5 mL. How many milliliters should the nurse administer? Record the answer using one decimal place. ______ mL

Desire 60 mg = x mL Have 125 mg/5 mL 125x = 300 X = 300 ÷ 125 = 2.4 mL

When monitoring fluids and electrolytes, the nurse recalls that the major cation-regulating intracellular osmolarity is: 1.Sodium 2.Potassium 3.Calcium 4.Calcitonin

2.Potassium

When performing a postoperative assessment, which parameter would alert the nurse to a common side effect of epidural anesthesia? 1.Decreased blood pressure 2.Increased oral temperature 3.Diminished peripheral pulses 4.Unequal bilateral breath sounds

1.Decreased blood pressure

A client with limited mobility is being discharged. To prevent urinary stasis and formation of renal calculi, the nurse should instruct the client to: 1.Increase oral fluid intake to 2 to 3 L per day. 2.Maintain bed rest after discharge. 3.Limit fluid intake to 1 L/day. 4.Void at least every hour

1.Increase oral fluid intake to 2 to 3 L per day.

A nursing supervisor sends unlicensed assistive personnel (UAP) to help relieve the burden of care on a short-staffed medical-surgical unit. Which tasks can be delegated to UAP? (Select all that apply.) 1.Taking routine vital signs. 2.Applying a sterile dressing. 3.Answering clients' call lights. 4 .Administering saline infusions. 5.Changing linens on an occupied bed. 6.Assessing client responses to ambulation.

1.Taking routine vital signs. 3.Answering clients' call lights. 5.Changing linens on an occupied bed.

A nurse addresses the needs of a client who is hyperventilating to prevent what complication? 1.Cardiac arrest 2.Carbonic acid deficit 3.Reduction in serum pH 4.Excess oxygen saturation

2.Carbonic acid deficit

What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess? 1.Rapid, thready pulse 2.Distended jugular veins 3.Elevated hematocrit level 4.Increased serum sodium level

2.Distended jugular veins

A client asks the nurse, "Should I tell my partner that I just found out I'm human immunodeficiency virus (HIV) positive?" What is the nurse's most appropriate response? 1."This is a decision you alone can make." 2."Do not tell your partner unless asked." 3."You are having difficulty deciding what to say." 4."Tell your partner that you don't know how you became sick."

3."You are having difficulty deciding what to say."

The nurse instructs a client that, in addition to building bones and teeth, calcium is also important for: 1.Bile production. 2.Blood production 3.Blood clotting. 4.Digestion of fats

3.Blood clotting.

A client that is scheduled for a surgical resection of the colon and creation of a colostomy for a bowel malignancy asks why preoperative antibiotics have been prescribed. The nurse explains that the primary purpose is to: 1.Decrease peristalsis. 2.Minimize electrolyte imbalance. 3.Decrease bacteria in the intestines. 4.Treat inflammation caused by the malignancy.

3.Decrease bacteria in the intestines.

A nurse reviews a medical record of a client with ascites. What does the nurse identify that may be causing the ascites? 1.Portal hypotension 2.Kidney malfunction 3.Decreased liver function 4.Decreased production of potassium

3.Decreased liver function

What is the maximum length of time a nurse should allow an intravenous (IV) bag of solution to infuse? 1.6 hours 2.12 hours 3.18 hours 4.24 hours

4. 24 hours

A client receiving steroid therapy states, "I have difficulty controlling my temper, which is so unlike me, and I don't know why this is happening." What is the nurse's best response? 1.Tell the client it is nothing to worry about. 2.Talk with the client further to identify the specific cause of the problem. 3.Instruct the client to attempt to avoid situations that cause irritation. 4.Interview the client to determine whether other mood swings are being experienced.

4.Interview the client to determine whether other mood swings are being experienced.

A health care provider prescribes famotidine (Pepcid) and magnesium hydroxide/aluminum hydroxide (Maalox) for a client with a peptic ulcer. The nurse should teach the client to take the Maalox at what time? 1.Only at bedtime, when famotidine is not taken. 2.Only if famotidine is ineffective. 3.At the same time as famotidine, with a full glass or water. 4.One hour before or two hours after famotidine.

4.One hour before or two hours after famotidine.

The nurse manager of the unit comes to work obviously intoxicated. The staff nurse's ethical obligation is to: 1.Call the security guard 2.Tell the nurse manager to go home 3.Have the supervisor validate the observation 4.Offer the nurse manager a large cup of coffee

3.Have the supervisor validate the observation

A client has been admitted with a urinary tract infection. The nurse receives a urine culture and sensitivity report that reveals the client has Vancomycin Resistant Enterococcus (VRE). After notifying the physician, which action should the nurse take to decrease the risk of transmission to others? 1.Insert a urinary catheter. 2.Initiate Droplet Precautions. 3.Move the client to a private room. 4.Use a high efficiency particulate air (HEPA) respirator during care

3.Move the client to a private room.

A nurse is reviewing a plan of care for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which prescription should the nurse question? 1.Oral psyllium (Metamucil) 2.Oral potassium supplement 3.Parenteral half normal saline 4.Parenteral albumin (Albuminar)

4.Parenteral albumin (Albuminar)

An assessment of the client on total parenteral nutrition (TPN) reveals a bounding pulse, distended jugular veins, dyspnea, and cough. What is the priority nursing intervention? 1.Ask the registered nurse start the client's infusion at a peripheral site 2.Slow the rate of the client's infusion of the TPN 3.Interrupt the client's infusion and notify the charge nurse or health care provider 4.Obtain the vital signs and continue monitoring the client's status

3.Interrupt the client's infusion and notify the charge nurse or health care provider

The nurse is providing post-procedure care for a client that had a liver biopsy. To prevent hemorrhage, it is the nurse's highest priority to place the client in what position? 1.Prone 2.High-Fowler's 3.On the right side 4.Trendelenburg

3.On the right side

A nurse is providing care to a client eight hours after the client had surgery to correct an upper urinary tract obstruction. Which assessment finding should the nurse report to the charge nurse or surgeon? 1.Incisional pain 2.Absent bowel sounds 3.Urine output of 20 mL/hour 4.Serosanguineous drainage on the dressing

3.Urine output of 20 mL/hour