Saunders week 14

A prescription reads 1000 mL of normal saline 0.9% to infuse over 8 hours. The drop factor is 15 drops (gtt)/1 mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.

31 drops per minute

The nurse hangs a 1000-mL intravenous (IV) bag of 5% dextrose in water (D5W) at 0700. The IV solution is to infuse at 80 mL/hr. At 1200, how much solution will be left to infuse? Fill in the blank.

600 mL

A primary health care provider prescribes 1000 mL of normal saline to infuse over 6 hours. The drop factor is 15 drops (gtt)/mL. The nurse prepares to set the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.

42 gtt/min

The primary health care provider's prescription reads levothyroxine, 100 mcg orally daily. The medication label reads levothyroxine, 0.1 mg per tablet. The nurse should administer how many tablet(s) to the client? Fill in the blank.

1 tab

A primary health care provider's prescription reads nitroglycerin grains 1/150 sublingually stat. The label on the bottle reads nitroglycerin 0.4 mg/tablet. The nurse prepares how many tablet(s) to administer the correct dose? Fill in the blank.

1 tablet(s)

An emergency room nurse is performing a cardiovascular assessment on a client. During auscultation of the heart sounds, the nurse hears these abnormal sounds. The nurse suspects that the client has which condition?

Ventricular hypertrophy It is a soft, low-pitched sound and is heard immediately before S1.

The nurse is estimating the body surface area of a child with a burn injury using the West nomogram. After noting the child's height (45 in [114 cm]) and weight (65 lb [29.5 kg]), the nurse reads the nomogram and determines that the body surface area is approximately which number? Refer to figure.

1.0

Ampicillin sodium, 250 mg in 50 mL of normal saline, is being administered over a period of 30 minutes. The drop factor is 10 gtt/mL. The nurse determines that the infusion is running at the prescribed rate if it is delivering how many drops per minute? Fill in the blank. Round your answer to the nearest whole number.

17 gtt/min

A primary health care provider prescribes heparin sodium 900 units per hour by continuous intravenous (IV) infusion. The pharmacy prepares the medication and delivers an IV bag labeled heparin 25,000 units in 500 mL of normal saline. An infusion pump must be used to administer the medication. How many milliliters per hour are required to deliver the prescribed dose? Fill in the blank.

18 mL/hr

A primary health care provider prescribes morphine sulfate 4 mg, intravenously (IV) stat, for a postoperative client in pain. The medication label states morphine sulfate 2 mg/mL. How many milliliters will the nurse prepare to administer to the client? Fill in the blank.

2

The primary health care provider prescribes a bolus of 500 mL of 0.9% normal saline to run over 4 hours. The drop factor is 10 gtt/mL. The nurse plans to adjust the flow rate to how many drops per minute? Fill in the blank. Round your answer to the nearest whole number.

21

The primary health care provider prescribes 2000 mL of 5% dextrose and half-normal saline to infuse over 24 hours. The drop factor is 15 drops (gtt) per mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.

21 gtt/min

primary health care provider prescribes 100 mL of normal saline to infuse over 1 hour. The drop factor is 15 drops (gtt)/mL. The nurse prepares to set the flow rate at how many drops per minute? Fill in the blank.

25

The primary health care provider prescribes 1000 mL of normal saline (NS) to be infused over a period of 10 hours. The delivery rate (drop factor) is 15 drops (gtt) per mL. The nurse should set the flow rate at how many drops per minute? Fill in the blank.

25 gtt/min

The nurse is reviewing the record of a client in the labor room and notes that the primary health care provider has documented that the fetal presenting part is at the −1 station. This documented finding indicates that the fetal presenting part is located at which area? Refer to figure.

3

The primary health care provider (PHCP) prescribes 1000 mL of normal saline to be infused over a period of 10 hours. The drop factor is 15 gtt/mL. The nurse adjusts the flow rate at how many drops per minute? Fill in the blank.

25

Normal saline 50 mL is to be given by intravenous (IV) infusion over a 15-minute period. The drop factor for the tubing is 10 gtt/mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Round your answer to the nearest whole number.

33 gtt/min

In what area of the chest would the nurse expect to auscultate these breath sounds?

These sounds are soft and low pitched and resemble a sighing or gentle rustling, and the inspiration phase is longer than the expiration phase. Anteriorly and posteriorly over the major bronchi 3

The clinic nurse is performing an assessment for a client who is complaining of shortness of breath. The client admits to smoking 1 pack of cigarettes per day for the past 10 years. The nurse determines that the client has a smoking history of how many pack-years? Fill in the blank.

10 pack years The standard method for quantifying the smoking history is to multiply the number of packs smoked per day by the number of years of smoking. The result is then recorded as the number of pack-years. The calculation for the number of pack-years for the client in this question who smokes 1 pack per day for 10 years is 1 pack × 10 years = 10 pack-years.

Amoxicillin/clavulanate potassium 500 mg orally every 6 hours is prescribed for a child with an upper respiratory infection. The medication is supplied as 200 mg/5 mL. How many milliliters will be administered in each dose? Fill in the blank.

12.5 ml

A primary health care provider's prescription reads acetaminophen liquid, 450 mg orally every 4 hours PRN (as needed) for pain. The medication label reads 160 mg/5 mL. The nurse prepares how many milliliters to administer 1 dose? Fill in the blank. Round your answer to the nearest whole number.

14 mL

A primary health care provider prescribes 500 mL of half normal saline to infuse over 8 hours. The drop factor is 15 drops (gtt)/mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.

16

A primary health care provider prescribes 1 unit of packed red blood cells to be infused over 4 hours. The unit of blood contains 250 mL. The drop factor is 15 drops (gtt)/mL. The nurse should set the flow rate at how many drops per minute? Fill in the blank. Round your answer to the nearest whole number.

16 gtt/min

A primary health care provider prescribes 500 mL of normal saline to infuse over 5 hours. The drop factor is 10 drops (gtt)/mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Round your answer to the nearest whole number.

17 gtt/min

The client is to receive 1000 mL of D5W at 100 mL/hr. The drop factor is 10 gtt/mL. The nurse adjusts the flow rate to deliver how many drops per minute? Fill in the blank. Round your answer to the nearest whole number.

17 gtt/min

A prescription reads 1000 mL of normal saline (NS) to infuse over 12 hours. The drop factor is 15 drops (gtt)/1 mL. The nurse prepares to set the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.

21 drops per minute

A primary health care provider prescribes 2000 mL of 5% dextrose and half normal saline to infuse over 24 hours. The drop factor is 15 drops (gtt)/mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Round your answer to the nearest whole number.

21 gtt/min

The primary health care provider's prescription for an antibiotic reads "500 mg in 250 mL of 5% dextrose in water and administer over 2 hours." The drop factor is 10 drops (gtt)/mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Round your answer to the nearest whole number.

21 gtt/min

An adult client trapped in a burning house has suffered burns to the back of the head, the upper half of the posterior trunk, and the back of both arms. Using the rule of nines, what percentage does the nurse determine the extent of the burn injury to be? Fill in the blank.

22.5% According to the rule of nines, the posterior side of the head equals 4.5%, the back of both arms equals 9%, and the upper half of the posterior trunk equals 9%, totaling 22.5%.

Gentamycin sulfate 80 mg in 100 mL normal saline is to be administered over 45 minutes. The drop factor is 15 drops (gtt) per mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.

33

A client with type 1 diabetes mellitus is admitted to the hospital with diabetic ketoacidosis and a serum glucose level of 789 mg/dL (45 mmol/L). The primary health care provider (PHCP) prescribes 10 units of regular insulin by intravenous (IV) bolus, followed by a continuous insulin infusion at a rate of 5 units/hr. The pharmacy sends 500 mL of normal saline solution containing 50 units of regular insulin. After administering the IV bolus of 10 units of regular insulin, the nurse sets the infusion pump flow rate of the normal saline solution containing 50 units of regular insulin to infuse at how many milliliters per hour to deliver 5 units/hr? Fill in the blank.

50 mL/hr

The nurse is assigned to change the surgical dressing on a client who has undergone abdominal surgery. After removing the old dressing, the nurse assesses the surgical site. Which should be the nurse's initial action if the appearance shown in the figure is observed? Refer to figure.

Apply a sterile nonadherent dressing. Wound dehiscence is partial or complete separation of the outer layers of the wound, sometimes described as splitting open of the wound. If this is noted, the nurse applies a sterile nonadherent dressing, such as a Telfa dressing or a saline dressing, to the wound and notifies the surgeon

The nurse is performing an assessment on a client with a head injury and notes that the client is assuming this posture. The nurse contacts the primary health care provider and reports that the client is exhibiting which posture? Refer to figure.

Decorticate rigidity In decorticate rigidity, the upper extremities (arms, wrists, and fingers) are flexed with adduction of the arms. The lower extremities are extended with internal rotation and plantar flexion. Decorticate rigidity indicates a hemispheric lesion of the cerebral cortex.

In what area of the chest would the nurse expect to auscultate these breath sounds?

Over the peripheral lung fields These sounds are a mixture of bronchial and vesicular breath sounds and are moderately pitched with a medium intensity. The inspiration and expiration phases are equal. Bronchial breath sounds are loud, high-pitched sounds that resemble air blowing through a hollow pipe. The expiration phase is louder and longer than the inspiration phase, and there is a distinct pause between the inspiration and expiration phases.

The nurse observes the client's sacrum and notes the following. How will the nurse document this in the client's medical record? Refer to figure.

Stage IV pressure ulcer

The primary health care provider prescribes the instillation of mydriatic eye drops to both eyes of a client. The nurse administers the eye drops and monitors the client for an effective response from the medication, as indicated by which response? Click on the image to indicate your answer.

dilated pupils

The primary health care provider prescribes hydromorphone 1 mg intravenously for a client in pain. The medication label states hydromorphone 2 mg/1 mL. The nurse should administer how many milliliters to the client? Fill in the blank.

0.5 mL

The primary health care provider prescribes 500 mL of 0.9% normal saline to run over 6 hours. The drop factor is 10 gtt/mL. The nurse adjusts the flow rate to run at how many drops per minute? Fill in the blank. Round your answer to the nearest whole number.

14

The nurse has a prescription to infuse 100 mL of antibiotic solution by the intravenous (IV) route over 1 hour. The tubing administration set has a drop factor of 10 drops (gtt) per mL. The nurse would regulate the roller clamp on the infusion set to deliver how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.

17 gtt/min

A prescription reads phenytoin 0.2 g orally twice daily. The medication label states that each capsule is 100 mg. The nurse prepares how many capsule(s) to administer 1 dose? Fill in the blank.

2 capsules

The primary health care provider prescribes digoxin 0.25 mg orally daily for a client with heart failure. The medication label states 0.125 mg per tablet. The nurse should administer how many tablet(s) to the client? Fill in the blank.

2 tablet(s)

A community health nurse is preparing to administer a tuberculin skin test. The nurse should select which syringe to administer the medication? Click on the image to indicate your answer.

3 A tuberculin skin test is done to determine exposure to tuberculosis. The nurse uses a tuberculin or a small hypodermic syringe for skin testing. The correct option identifies a tuberculin syringe that is used for skin testing.

A primary health care provider prescribes 3000 mL of 5% dextrose in water to run over a 24-hour period. The drop factor is 15 drops (gtt) per 1 mL. The nurse adjusts the flow rate to run at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.

31

A client in week 35 of her pregnancy is placed on the fetal heart monitor for a nonstress test (NST) as a result of her complaints of decreased fetal movement. Twenty minutes after placing the client on the monitor, the nurse sees the following monitor strip and makes which conclusion regarding the NST? Refer to figure.

The FHR is reactive, with a baseline of 130 beats/minute, moderate variability, and no decelerations. The criteria for a reactive NST are 2 or more accelerations of 15 beats/minute, lasting for 15 seconds over a 20-minute period; normal baseline rate (110 to 160 beats/minute); and variability amplitude of 10 or more beats/minute. No decelerations are noted on the fetal monitor strip. The fetal monitor strip identifies these criteria; therefore, option 2 is correct.

The nurse is preparing to care for a client admitted to the emergency department with a diagnosis of diabetic ketoacidosis (DKA). The nurse gathers supplies and obtains which type of insulin, anticipating that it will be initially prescribed for the client? Click on the image to indicate your answer.

regular

The nurse has performed a nonstress test on a pregnant client and is reviewing the fetal monitor strip. How should the nurse document this finding in the client's medical record? Refer to figure.

Normal A reactive nonstress test is a normal result. To be considered reactive, the baseline fetal heart rate must be within normal range (120 to 160 beats/minute) with good long-term variability. In addition, 2 or more fetal heart rate accelerations of at least 15 beats/minute must occur, each with a duration of at least 15 seconds, in a 20-minute interval.

The nurse is caring for a client who suddenly starts complaining of palpitations, restlessness, and anxiety. The nurse obtains a stat electrocardiogram (ECG) which shows this rhythm. Refer to figure. The nurse should perform which actions in anticipation of appropriate medication therapy with amiodarone?

Obtain a syringe and administer 150 mg over 1 minute via intravenous push followed by a maintenance dose. The dysrhythmia shown in the figure is atrial fibrillation with a rapid and irregular ventricular rate. This dysrhythmia is life-threatening due to the risk for clot formation and inadequate cardiac output. Amiodarone is a class III antidysrhythmic medication that is highly effective against both atrial and ventricular dysrhythmias. When used in emergent situations for life-threatening dysrhythmias, this medication should be given using an infusion pump so an accurate dose can be administered. An initial loading dose of 150 mg over 10 minutes should be infused as a bolus using the pump. Next, maintenance doses of 360 mg over 6 hours, then 540 mg over 18 hours, followed by 720 mg over 24 hours are infused. The infusion is titrated based on blood pressure.

Assessment findings of an infant admitted to the hospital reveal a machinery-like murmur on auscultation of the heart and signs of heart failure. The nurse reviews congenital cardiac anomalies and identifies the infant's condition as which disorder? Refer to figure (the circled area) to determine the condition.

Patent ductus arteriosus A patent ductus arteriosus is failure of the fetal ductus arteriosus (artery connecting the aorta and the pulmonary artery) to close. A characteristic machinery-like murmur is present, and the infant may show signs of heart failure.

The nurse has just received a unit of packed red blood cells from the blood bank for transfusion to an assigned client. The nurse is careful to select tubing especially made for blood products, knowing that this tubing is manufactured with which item? Click on the image to indicate your answer.

The tubing used for blood administration has an in-line filter. The filter helps to ensure that any particles larger than the size of the filter are caught in the filter and are not infused into the client. 4

The nurse is preparing to administer a soapsuds enema to a preoperative client. In which position should the nurse place the client to administer the enema? Click on the image to indicate your answer.

To administer an enema, the nurse assists the client into the left side-lying (Sims') position with the right knee flexed. This position allows the enema solution to flow downward by gravity along the natural curve of the sigmoid colon and rectum, thereby improving the retention of solution.