MS Week 4 Practice Assessment
A nurse is caring for an infant who has a congenital heart defect. Which of the following defects is associated with increased pulmonary blood flow? A) Coarctation of the aorta B) Patent ductus arteriosus C) Tetralogy of Fallot D) Tricuspid atresia
ANS: B) Patent ductus arteriosus RATIONALE: With patent ductus arteriosus, the area between the pulmonary artery and aorta remains open, allowing the blood to flow through the patent ductus arteriosus and back to the pulmonary artery and lungs.
A 46-year-old African-American man is in an outpatient clinic for a physical examination. His BP is 126/84 mm Hg. his BML is 24, and he reports no previous medical problems. Which of the following actions should the nurse take? A) Schedule his next appointment for 1 year from now. B) Provide information about how to reduce risk factors of hypertension. C) Schedule an appointment for a prostate-specific antigen (PSA) test. D) Provide information for a weight loss plan that includes increasing physical activity.
ANS: B) Provide information about how to reduce risk factors of hypertension. RATIONALE: African Americans in the United States have a high incidence of hypertension. This client is prehypertensive. A blood pressure of 124/82 mm Hg, in addition to the client being of African American descent, places him at risk of developing later stages of hypertension. Other risk factors include smoking, obesity, stress, hyperlipidemia, physical inactivity, excessive alcohol consumption, and a family history of hypertension. The nurse should reinforce teaching about the risk factors for hypertension and schedule a follow-up appointment to recheck the client's blood pressure.
A nurse is preparing to administer amoxicillin 30 mg/kg/day divided doses every 12 hr to a toddler who weighs 33 lbs. Available is amoxicillin 200 mg/5 mL suspension. How many mL should the nurse administer every 12 hr? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
ANS: 5.6 Explanation: Follow these steps for the preliminary conversions:STEP 1: What is the unit of measurement the nurse should calculate? mgSTEP 2: Set up an equation and solve for X.mg x kg/day = X30 mg X 15 kg/day = 450 mgSTEP 3: Round if necessary.STEP 4: Reassess to determine whether the amount makes sense. If the prescription reads 30 mg/kg/day to divide equally every 12 hr and the toddler weighs 15 kg, it makes sense to give 450 mg/day or 225 mg every 12 hr.Ratio and ProportionSTEP 1: What is the unit of measurement the nurse should calculate? mLSTEP 2: What is the dose the nurse should administer? Dose to administer = Desired 225 mgSTEP 3: What is the dose available? Dose available = Have 200 mgSTEP 4: Should the nurse convert the units of measurement? NoSTEP 5: What is the quantity of the dose available? 5 mLSTEP 6: Set up an equation and solve for X.Have/Quantity = Desired/X200 mg/5 mL = 225 mg/X mLX = 5.625 mLSTEP 7: Round if necessary. 5.625 = 5.6 mL
A nurse is reinforcing discharge teaching with a client about dietary sources of potassium. Which of the following statements by the client indicates an understanding of the teaching? A) "I will eat cantaloupe for my morning snack." B) "I can plan to eat rice instead of baked potatoes." C) "I will miss eating yogurt every day for breakfast." D) "Adding pecans will be a change I can readily make."
ANS: A) "I will eat cantaloupe for my morning snack." RATIONALE: The client should choose fruits such as cantaloupe, bananas, apricots, and peaches as food sources high in potassium. Therefore, the nurse should identify this statement as indicating an understanding of the teaching.
While auscultating a client's heart sounds, the nurse hears turbulence between S1 and S2. The nurse should document this finding as which of the following? A) A systolic murmur B) A third heart sound (S3) C) An expected heart sound D) A fourth heart sound (S4)
ANS: A) A systolic murmur Rationale: Cardiac murmurs are relatively loud, turbulent sounds the nurse can hear between the usual, expected heart sounds. They create a whooshing or a swishing sound. Those between S1 and S2 are systolic murmurs. Those between S2 and the next S1 are diastolic murmurs.
A nurse is assisting with collecting data on a client who is on a continuous ECG monitor. The client's ECG tracing shows no identifiable P waves and an irregular ventricular rate. The nurse should recognize the client is experiencing which of the following cardiac dysrhythmias? A) Atrial fibrillation B) Complete heart block C) Sinus tachycardia D) First degree AV block
ANS: A) Atrial fibrillation RATIONALE: Atrial fibrillation is a supraventricular rhythm that is characterized by no identifiable P waves and a variable ventricular rate.
A nurse enters a client's room and finds the client pulseless. The nurse knows the client's family has requested do-not-resuscitate (DNR) status from the provider, but the provider has not written the prescription yet. Which of the following actions should the nurse take? A) Call the emergency response team. B) Begin cardiopulmonary resuscitation without calling the team. C) Call the provider for a stat DNR prescription. D) Respect the family's wishes and do nothing.
ANS: A) Call the emergency response team. RATIONALE: Unless the provider writes a DNR prescription, the nurse must make every effort to resuscitate the client. The nurse should follow the facility's protocol for initiating the emergency response procedure.
A nurse is checking the apical pulse of a client who is taking several cardiovascular medications. Which of the following actions should the nurse take? A) Count the apical pulsations for a full minute. B) Check the apical pulse with a Doppler device. C) Use the diaphragm of the stethoscope to listen to the apical pulsations. D) Press the stethoscope firmly against the client's skin.
ANS: A) Count the apical pulsations for a full minute. RATIONALE: For clients who have a regular pulse and no cardiovascular problems, the nurse should count the apical pulsations for 30 seconds and multiply by 2. For this client, the nurse should count for 60 seconds.
A nurse is reviewing the laboratory report of a client who is receiving treatment for a high fever and a viral infection. Which of the following findings should the nurse expect? A) Elevated T-cell count B) Decreased leukocyte count C) Elevated hemoglobin level D) Decreased albumin level
ANS: A) Elevated T-cell count RATIONALE: A high T-cell count (greater than 2,500/mm3, also known as lymphocytosis) occurs with a viral infection or a chronic disease such as lymphoma. These cells (along with B cells) fight chronic bacterial and acute viral infections.
A nurse is reviewing the prescriptions for a newly admitted client who is to undergo cardiac testing. For which of the following procedures should the nurse verify that the client has given written informed consent? A) Exercise ECG stress test B) Echocardiogram C) CT scan without contrast dye D) Electrocardiogram
ANS: A) Exercise ECG stress test RATIONALE: When undergoing an exercise ECG stress test, the client exercises on equipment, such as a treadmill, causing risk to the client. Therefore, the client must give written informed consent.
A nurse in a clinic is reviewing teaching about food choices with a client who has recently begun taking warfarin. The nurse should instruct the client to limit consumption of which of the following? A) Kale B) Cantaloupe C) Whole grain bread D) White beans
ANS: A) Kale RATIONALE: Kale is a green leafy vegetable that is rich in vitamin K. While taking warfarin, clients are encouraged to limit vitamin K, as this decreases the medication's effectiveness. Certain greens such as Brussels sprouts, kale, and mustard greens are very high in vitamin K and should not be consumed in large quantities.
A nurse is caring for a client who has a new prescription for warfarin. The nurse should use the results of which of the following diagnostic tests to monitor the effect of this therapy? A) Prothrombin time (PT) B) Platelet count C) White blood cell count (WBC) D) Activated partial thromboplastin time (aPTT)
ANS: A) Prothrombin time (PT) RATIONALE: The PT, reported as an INR, is used to monitor warfarin therapy.
A nurse is assisting with the care of a client who is receiving packed red blood cells. During the infusion, the client states, 'My heart is racing.' The nurse notes that the client's face has become flushed. Which of the following actions should the nurse take first? A) Stop the transfusion. B) Notify the charge nurse. C) Obtain the client's vital signs. D) Administer prescribed diphenhydramine.
ANS: A) Stop the transfusion. RATIONALE: The nurse should identify flushing and tachycardia as manifestations of an allergic reaction to the blood transfusion. The first action the nurse should take is to stop the transfusion immediately to prevent further reaction.
A nurse is caring for a client who has been taking warfarin and has a prothrombin time of 30 seconds. Which of the following medications should the nurse anticipate the provider to prescribe? A) Vitamin K B) Heparin C) Prednisone D) Ferrous sulfate
ANS: A) Vitamin K RATIONALE: A prothrombin time of 30 seconds indicates the clotting time is prolonged and bleeding could occur. Vitamin K injection antagonizes the actions of warfarin and serves as an antidote to the medication; therefore, the nurse should anticipate the provider will prescribe vitamin K.
A nurse is collecting data about a client's circulatory system. Which of the following pulse sites should the nurse avoid checking bilaterally at the same time? A) Brachial B) Carotid C) Femoral D) Popliteal
ANS: B) Carotid RATIONALE: The nurse should avoid evaluating the carotid pulse bilaterally at the same time. This action can induce syncope by reducing blood flow to the brain and causing a reflex drop in the blood pressure and heart rate.
A nurse is caring for a client who has a hemoglobin of 10.8 g/dL and a hematocrit of 30%. The nurse should expect the client is at risk for which of the following conditions? A) Prolonged bleeding B) Cellular hypoxia C) Impaired immunity D) Fluid retention
ANS: B) Cellular hypoxia RATIONALE: The client's laboratory results indicate anemia, which places the client at risk for cellular hypoxia.
A nurse is collecting data from a client who reports a sudden onset of shortness of breath, fatigue , and dizziness. Electrocardiography indicates the client is experiencing atrial fibrillation. Which of the following medications should the nurse expect to administer? A) Vitamin K B) Digoxin C) Atropine D) Magnesium
ANS: B) Digoxin RATIONALE: The client who is experiencing atrial fibrillation has an elevated heart rate that is irregular due to rapid impulses being sent to the atrioventricular (AV) node. Digoxin decreases the heart rate and the rate of AV conduction. This medication is used in the treatment of atrial fibrillation and heart failure.
A nurse is collecting data from a client who has gastroesophageal reflux (GERD) and reports having heartburn every night. Which of the following actions should the nurse identify as a contributing factor to the client's heartburn? A) Sleeping on a large wedge-style pillow B) Drinking orange juice regularly C) Consuming low-fat meats D) Eating dinner early in the evening
ANS: B) Drinking orange juice regularly RATIONALE: Spicy and acidic foods, such as orange juice, irritate inflamed esophageal tissue and decrease the pressure of the lower esophageal sphincter, causing heartburn.
A nurse is assisting with the care of a client who has infective endocarditis. Which of the following manifestations should the nurse identify as a complication of this disorder? A) A heart murmur B) Dyspnea C) ever D) Petechiae
ANS: B) Dyspnea RATIONALE: Emboli is a serious complication due to emboli arising in the right heart chambers which will terminate in the lungs, causing dyspnea, and left-chamber emboli may travel anywhere in the arteries, reaching the spleen, kidneys, brain, lungs, or extremities.
A nurse is collecting data on a client who has infective endocarditis. The nurse should recognize which of the following findings is the priority to report to the provider? A) Anorexia B) Dyspnea C) Fever D) Malaise
ANS: B) Dyspnea RATIONALE: When using the airway, breathing, circulation (ABC) approach to client care, the nurse determines the priority finding is dyspnea. Dyspnea can be an indication of left-sided heart failure, or a pulmonary infarction due to embolization; therefore it is the priority finding to report.
A nurse is collecting data from a client who reports taking several herbal supplements. Which of the following supplements should the nurse tell the client can increase anticoagulation effects and thus increase risk for bleeding? A) Valerian B) Feverfew C) St. John's wort D) Saw palmetto
ANS: B) Feverfew RATIONALE: Feverfew is reported to reduce frequency of migraine attacks. Feverfew is fairly well tolerated, but the client should be informed that it can decrease platelet aggregation and can increase the risk for bleeding. In addition, the nurse should report the use of feverfew and other herbal supplements to the client's provider.
A nurse is collecting data from a client who is receiving continuous cardiac monitoring that is indicating premature ventricular contractions (PVCs). Which of the following findings should the nurse expect when assessing the client? A) Increase in point of maximum impulse (PMI) B) Irregular pulsations C) S3 heart sounds D) Bradycardia
ANS: B) Irregular pulsations RATIONALE: PVCs are early ventricular polarizations that occur before the atrial contraction is complete. This disrupts the normal heart rhythm and is auscultated as an irregular beat. PVCs have a wide variety of causes, including electrolyte imbalances, myocardial ischemia, anxiety, caffeine, or use of certain medications. The client may describe the PVCs as a feeling of "palpitations" or "skipped beats."
A nurse is reinforcing teaching with a newly licensed nurse about reading a client's ECG tracing. The nurse should include in the teaching that which of the following ECG components represents the time it takes for ventricular depolarization and repolarization? A) PR interval B) QT interval C) ST segment D) QRS complex
ANS: B) QT interval RATIONALE: The QT interval reflects the time it takes for ventricular depolarization and repolarization. The nurse should measure the QT interval from the start of the QRS complex to the end of the T wave.
A nurse is reinforcing teaching with a client who wants to increase her daily intake of omega-3 fatty acids. Which of the following foods should the nurse suggest the client increase? A) Blueberries B) Soybean oil C) Citrus fruits D) Green tea
ANS: B) Soybean oil RATIONALE: Soybean oil is a good source of the omega-3 fatty acids.
A nurse is reinforcing teaching for a client who has a new prescription for warfarin. Which of the following information should the nurse include? A) Mild nosebleeds are common during initial treatment. B) The client should use an electric razor while on this medication. C) If he misses a dose, he should double the dose at the next scheduled time. D) Warfarin increases the risk for deep vein thrombosis.
ANS: B) The client should use an electric razor while on this medication. RATIONALE: Warfarin, an anticoagulant, increases the client's risk for bleeding. The nurse should teach the client safety measure, such as using an electric razor, to decrease the risk for injury and bleeding.
A nurse is caring for a newborn. How many blood vessels should the nurse expect to observe in the newborn's umbilical cord? A) One artery and one vein B) Two arteries and one vein C) Two veins and one artery D) Two arteries and two veins
ANS: B) Two arteries and one vein RATIONALE: The vein carries oxygenated blood to the fetus, and the two arteries carries unoxygenated blood back to the placenta.
A nurse is collecting data about a client's cardiac functioning. The nurse auscultates an S3 sound. Which of the following causes should the nurse suspect? A) Atrial gallop B) Ventricular gallop C) Closing of the atrioventricular valves D) Closing of semilunar valves
ANS: B) Ventricular gallop RATIONALE: An S3 sound represents a ventricular gallop. Possible causes are hypertension and heart failure.
A nurse is caring for an older adult client who reports occasional. The nurse should inform the client that straining while defecating can cause which of the following? A) Dilated pupils B) Dysrhythmias C) Diarrhea D) Gastric ulcer
ANS: B) Dysrhythmias RATIONALE: When the client exerts pressure to expel feces, he uses the Valsalva maneuver, with which he contracts his abdominal muscles voluntarily and exhales against a closed airway while bearing down. When he exhales and releases the sudden pressure, dysrhythmias can occur.
A nurse is preparing to perform a 12-lead electrocardiogram (ECG). Which of the following instructions should the nurse provide to the client? A) "I will be placing some electrodes on your scalp." B) "Be sure to wear this equipment for the next 24 hours." C) "Try to remain still once I have attached the gel pads." D) "You might feel some slight tingling during the procedure."
ANS: C) "Try to remain still once I have attached the gel pads." RATIONALE: The nurse should stress the importance of lying still during the ECG to prevent artifact from occurring and allow for clear results when interpreted by the provider.
A nurse is reinforcing teaching with a newly licensed nurse about reading a client's ECG tracing. The nurse should include in the teaching that the P wave represents which of the following cardiac electrical activities? A) Ventricular depolarization B) Late ventricular repolarization C) Atrial depolarization D) Early ventricular repolarization
ANS: C) Atrial depolarization RATIONALE: The P wave represents atrial depolarization, typically initiated in the sinoatrial node.
During a change-of-shift report, a nurse sees that a client's IV bag of 0.9% sodium has 900 mL of fluid left in it. The nurse makes rounds 30 min later and notes that the IV bag is empty. Which of the following actions should the nurse take? A) Elevate the head of the bed to high Fowler's. B) Request NPO status for the client. C) Check the client's respiratory rate and lung sounds. D) Measure the client's temperature.
ANS: C) Check the client's respiratory rate and lung sounds. RATIONALE: The nurse should collect data immediately to identify any indications of fluid-volume excess. To do so, the nurse should listen to the client's lungs for dyspnea and rales.
A nurse is collecting data from a client who has mitral stenosis. Which of the following findings is a manifestation of this condition? A) Angina B) Cyanosis C) Dyspnea on exertion D) S3 heart sound
ANS: C) Dyspnea on exertion RATIONALE: Due to narrowing of the valve, pressure in the lungs leads to dyspnea on exertion.
A nurse in a provider's office is collecting data from a client who reports dyspnea and fatigue. The nurse determines that the client also has tachycardia and edema. Which of the following disorders should the nurse suspect? A) Asthma B) Aortic valve regurgitation C) Heart failure D) Aortic stenosis
ANS: C) Heart failure RATIONALE: Fatigue and tachycardia are early manifestations of heart failure, which also causes dyspnea and peripheral edema.
A nurse is collecting data from a client who has osteomyelitis following a compound fracture of the right lower leg. Which of the following findings should the nurse expect? A) Low erythrocyte sedimentation rate (ESR) B) Pallor of the extremity C) High white blood cell count (WBC) D) Extremity is cool to the touch
ANS: C) High white blood cell count (WBC) RATIONALE: Osteomyelitis is an infectious process involving a bacterial infection of the bone. The causative organism is frequently Staphylococcus aureus. The body's response to the bacterial infection is to increase WBCs in order to fight the infection.
A nurse is collecting data from a client who has atrial fibrillation. When documenting the quality of the client's pulse, which of the following terms should the nurse use? A) Slow B) Not palpable C) Irregular D) Bounding
ANS: C) Irregular RATIONALE: With atrial fibrillation, multiple ectopic foci stimulate the atria to contract. The AV node is unable to transmit all of these impulses to the ventricles, resulting in a pattern of highly irregular ventricular contractions and thus an irregular pulse.
A nurse is assisting with the care of a client who is receiving heparin by IV infusion. Which of the following medications should the nurse have available in the event of an overdose? A) Ferrous sulfate B) Glucagon C) Protamine D) Vitamin K
ANS: C) Protamine RATIONALE: Protamine combines with heparin to form a stable compound, which then neutralizes the anticoagulant effect of heparin.
A nurse is assisting with the care of a client who has septic shock and is at risk for disseminated intravascular coagulation (DIC). Which of the following nursing statements indicates an understanding of the condition? A) "DIC is controllable with lifelong heparin usage." B) "DIC is characterized by an elevated platelet count." C) "DIC is caused by abnormal coagulation involving fibrinogen." D) "DIC is a genetic disorder involving vitamin K deficiency."
ANS: C) "DIC is caused by abnormal coagulation involving fibrinogen." RATIONALE: The nurse should understand that DIC is caused by an abnormal coagulation following fibrinogen levels below the expected reference range.
A nurse is collecting data from a client who is 1 day postpartum. Which of the following findings requires immediate intervention by the nurse? A) Decreased urge to void B) Increased urine output C) Displaced fundus from the midline D) Fundal height below the umbilicus
ANS: C) Displaced fundus from the midline RATIONALE: Uterine atony results from the inability of the uterine muscle to contract adequately after birth. This can lead to postpartum hemorrhage. A distended bladder can cause uterine atony and lateral displacement from the midline of the lower abdomen, usually to the right. This occurs because the distended bladder pushes the uterus up and to the side, which prevents it from contracting firmly. This finding requires immediate intervention by the nurse.
A nurse is reinforcing teaching with an adult client who has been newly diagnosed with a heart murmur. Which of the following statements should the nurse make? A) "A heart murmur is a high-pitched sound due to a narrow valve." B) "A heart murmur is an extra sound due to blood entering an inflexible chamber." C) "This means that there is some inflammation around your heart." D) "This indicates turbulent blood flow through a valve."
ANS: D) "This indicates turbulent blood flow through a valve." RATIONALE: Turbulent blood flow through a valve generates a murmur, possibly due to a malfunctioning valve, increased blood flow, or a type of defect in the structures of or around the heart.
A nurse is reinforcing teaching with a client who is taking warfarin about monitoring its therapeutic effect. The nurse should issue which of the following statements about the provider's use of the international normalized ratio (INR)? A) "You will need to fast 12 hours prior to having the test completed." B) "This is the only test available for anticoagulant therapy monitoring." C) "You will need the test done twice per month starting this medication." D) "This is a standardized test, so it eliminates the variations different laboratories report in prothrombin times."
ANS: D) "This is a standardized test, so it eliminates the variations different laboratories report in prothrombin times." RATIONALE: The nurse should reinforce to the client that the INR is a standardized test, which means that the result will be the same, no matter which laboratory performs this test.
A nurse is reinforcing health screening education with a group of clients. The nurse should recognize that which of the following clients has the greatest risk for hypertension? A) A client who is of Asian ethnicity B) A female client who is 44-years-old C) A male client who is 53-years-old D) A client who is African American
ANS: D) A client who is African American RATIONALE: The incidence of hypertension is highest in African Americans compared to European Americans. African Americans tend to develop hypertension at an earlier age and experience complications, such as stroke, heart disease, and kidney disease. Hypertension-related deaths are also higher among African Americans.
A nurse is checking for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect? A) Apical pulse rate different than the radial pulse rate B) Increase in heart rate by 20% when standing C) Drop in systolic BP by 20 mm Hg when moving from a lying to a sitting position D) Drop in systolic BP more than 10 mm Hg on inspiration
ANS: D) Drop in systolic BP more than 10 mm Hg on inspiration RATIONALE: The nurse should expect the client who has constrictive pericarditis to have a decrease in systolic pressure by more than 10 mm Hg during inspiration, which is paradoxical blood pressure. This is also an expected finding for a client who has pulmonary hypertension or pericardial tamponade.
A nurse is contributing to the plan of care for a client who is 24 postoperative following an aortic valve replacement with a biologic valve. Which of the following interventions should the nurse include in the plan? A) PTT levels B) Apply a cooling blanket C) Provide opioid medications on an as needed basis D) Monitor daily weight
ANS: D) Monitor daily weight RATIONALE: The client who has had an aortic valve replacement is weighed daily to monitor for the presence of retained fluids which might indicate a decrease in cardiac output, a complication of the surgery.
A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect? A) Frothy sputum B) Dyspnea C) Orthopnea D) Peripheral edema
ANS: D) Peripheral edema RATIONALE: Peripheral edema is caused by weakness in the right side of the heart, allowing blood to back up into the venous system and leak into interstitial tissues.
A nurse is collecting data from a client who has a prosthetic aortic valve and takes warfarin daily at bedtime. Which of the following data is the priority findings for the nurse to report to the provider? A) The client keeps a small supply of vitamin K tablets on hand for emergency use. B) The client consistently eats fish for dinner twice weekly. C) The client sprinkles flaxseeds on breakfast food every day. D) The client uses garlic as a daily dietary supplement.
ANS: D) The client uses garlic as a daily dietary supplement. RATIONALE: The nurse should be aware that the use of garlic as a dietary supplement might potentiate the action of warfarin and may cause bleeding. Therefore, use of garlic is the finding to report to the provider. The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client.
A nurse is preparing to administer 0.9% sodium chloride (NS) 100 mL IV to infuse over 4 hr. The drip factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole)
ANS: x= 25 Explanation: Ratio and Proportion and Desired Over HaveSTEP 1: What is the unit of measurement the nurse should calculate? gtt/min STEP 2: What is the volume the nurse should infuse? 100 mL STEP 3: What is the total infusion time? 4 hr STEP 4: Should the nurse convert the units of measurement? Yes (min does not equal hr) 1 hr/60 min = 1 hr/X hr X = 240 min STEP 5: Set up an equation and solve for X. Volume (mL)/Time (hr) x drop factor (gtt/mL) = X100 mL/240 min x 60 gtt/min = X gtt/min X = 25
A nurse is assisting with care of a client who has a prescription for 3,000 mL of intravenous fluids over the next 24 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round to the nearest whole number)
ANS: 125/hr RATIONALE: STEP 1: What is the unit of measurement the nurse should calculate? mL/hr STEP 2: What is the volume the nurse should infuse? 3,000 mL STEP 3: What is the total infusion time? 24 hr STEP 4: Should the nurse convert the units of measurement? No STEP 5: Set up an equation and solve for X. Volume (mL)/Time (hr) = X mL/hr 3,000 mL/24 hr = X mL/hr X = 125/hr STEP 6: Round if necessary. STEP 7: Reassess to determine whether the amount to administer makes sense. If the prescription reads 3,000 24 hr, it makes sense to administer 125 mL/hr. The nurse should set the IV pump to deliver 125 mL/hr.
A nurse is caring for a client who has a prescription for metoprolol. The nurse measures the client's vital signs and notes that the client's apical heart rate is 49/min. The nurse should prepare to administer which of the following medications? A) Digoxin B) Atropine C) Bethanechol D) Neostigmine
ANS: B) Atropine Rationale: Atropine is a muscarinic agonist and it is used to treat bradycardia.
