AH1 fundamentals- week 8

A nurse is preparing to infuse a 250-mL unit of packed RBCs over 2 hr. The drop factor of the manual IV tubing is 15 gtts/mL. The nurse should adjust the flow rate to deliver how many drops per minute? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) ______ gtt/min

31 gtt/min Correct Rationale: Follow these steps to calculate the infusion rate: Step 1: What is the unit of measurement the nurse should calculate? gtt/min Step 2: What is the volume the nurse should infuse? 250 mL Step 3: What is the total infusion time? 2 hr Step 4: Should the nurse convert the units of measurement? Yes (min does not equal hr) 1 hr/60 min = 2 hr/X min X = 120 min Step 5: Set up an equation and solve for X. Volume (mL)/Time (hr) x drop factor (gtt/mL) = X 250 mL/120 min x 15 gtt/mL = X gtt/min 31.25 = X Step 6: Round if necessary. 31.25 = 31 Step 7: Reassess to determine whether the amount to administer makes sense. If the prescription reads one 250-mL unit of packed cells to infuse IV over 2 hr, it makes sense to administer 31 gtt/min. The nurse should adjust the manual IV infusion to deliver the packed RBCs at 31 gtt/min.

A nurse at an extended-care facility is instructing a class of assistive personnel (AP) about client use of assistive devices during ambulation. Which of the following instructions should the nurse give the APs about the clients' use of a cane? A. "When the client moves, he should move the cane forward first." B. "The client should hold the cane on the weak side of his body." C. "The grip should be level with the client's waist." D. "The client should first move the strong leg, then the weak one."

A. "When the client moves, he should move the cane forward first." Rationale: When the client moves, he should first move the cane forward about 30.5 cm (12 in). Then, he should move the weak leg even with the cane. Finally, he should bring the strong leg forward and ahead of the cane and his weak leg.

A charge nurse is anticipating the admission of four clients and planning their room assignments. Which of the following clients should the nurse assign to the room closest to the nurses' station? A. A client who sustained a head injury and is having periods of confusion B. A client who reports a severe migraine headache C. A client who has a suspected diagnosis of tuberculosis (TB) D. A client who has a history of atrial fibrillation and is on continuous ECG monitoring.

A. A client who sustained a head injury and is having periods of confusion Rationale: A client who sustained a head injury and is confused is at risk for seizures. The nurse should place this client in a room near the nurses' station so that he can be closely monitored to prevent injury if a seizure occurs.

An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of the following vital signs should the nurse re-measure? A. BP B. Respiratory rate C. Pulse rate D. Temperature

A. BP Rationale: A nurse who is supervising an AP's work is accountable for the work that the AP completes. Therefore, the nurse should verify anything that seems unusual. The BP the AP reported is low; therefore, the nurse should verify that this result is accurate before taking any other actions.

A nurse is teaching a class of older adults about the expected physiologic changes of aging. Which of the following changes should the nurse include in the discussion? (Select all that apply.) A. More difficulty seeing due to a greater sensitivity to glare B. Decreased cough reflex C. Decreased bladder capacity D. Decreased systolic blood pressure E. Dehydration of intervertebral discs

A. More difficulty seeing due to a greater sensitivity to glare B. Decreased cough reflex C. Decreased bladder capacity E. Dehydration of intervertebral discs Rationale: More difficulty seeing due to a greater sensitivity to glare is correct. Older adults have an increased susceptibility to glare, greater difficulty in seeing at low levels of illumination, and alterations in color perception. Decreased cough reflex is correct. Older adults have a decreased

A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort? A. Obtain a pair of slipper-socks for the client. B. Rub the client's feet briskly for several minutes. C. Increase the client's oral fluid intake. D. Place a moist heating pad under the client's feet.

A. Obtain a pair of slipper-socks for the client. Rationale: In cold weather or when the client's feet are cold, he should wear extra socks or slipper socks to help provide warmth and increase his level of comfor

A nurse is working with a licensed practical nurse (LPN) to care for a client who is receiving a continuous IV infusion. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site? A. "The infusion rate has stopped but the tubing is not kinked." B. "The area surrounding the insertion site feels warm to the touch." C. "There is fluid leaking around the insertion site." D. "There is no blood return when the tubing is aspirated."

B. "The area surrounding the insertion site feels warm to the touch." Rationale: The IV fluid is at room temperature, so the area around the injection site will feel cool, not warm, to the touch when the IV is infiltrated. A warm area around the injection site indicates infection or phlebitis

A nurse is caring for a client who has an NG tube. The nurse tests the pH of the secretions to determine if the tube is correctly placed. Which of the following readings should the nurse expect? A. 6.0 B. 4.0 C. 7.0 D. 8.0

B. 4.0 Rationale: This is an acidic pH, which is consistent with gastric drainage. This indicates that the NG tube is correctly placed.

A nurse is caring for a client who has active pulmonary tuberculosis (TB). The client requires airborne precautions and is receiving multidrug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiology department for a chest x-ray? A. Ask the x-ray technician to come to the client's room to obtain a portable x-ray. B. Have the client wear a mask. C. Notify the x-ray department that the client requires airborne precautions. D. Wear a filtration mask and gloves during transport.

B. Have the client wear a mask. Rationale: When a client who has a communicable disease must leave his room, it is important to protect everyone with whom the client comes in contact. Having the client wear a mask protects others from airborne particles should the client cough.

A nurse is providing preoperative teaching by demonstrating diaphragmatic breathing to a client who is scheduled for surgery in the morning. Which of the following actions should the nurse include in the demonstration? A. Place her hands on the sides of her rib cage. B. Inhale slowly and evenly through her nose. C. Hold her breath for at least 10 seconds. D. Exhale forcefully through the nose.

B. Inhale slowly and evenly through her nose. Rationale: The nurse should inhale slowly and evenly through her nose until chest expansion is maximized.

A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take? A. Place the wheelchair at a 90° angle to the bed. B. Lock the wheels of the bed and the wheelchair. C. Acquire the help of several people to lift the client. D. Elevate the bed to a position of comfort for the nurse.

B. Lock the wheels of the bed and the wheelchair. Rationale: The nurse should keep the wheels of the bed and the wheelchair in the locked position to prevent them from moving when transferring a client

A nurse is caring for an older adult client who was alert and oriented at admission, but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs? A. Call the family and ask them to stay with the client. B. Move the client to a room closer to the nurses' station. C. Apply wrist and leg restraints to the client. D. Administer medication to sedate the client.

B. Move the client to a room closer to the nurses' station. Rationale: This will make it easier for the staff to observe the client, should the client behave in an unsafe manner.

A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. Which of the following actions should the nurse should take? A. Observe the client before taking further action. B. Perform the Heimlich maneuver. C. Assist the client to the floor and begin mouth-to-mouth resuscitation. D. Slap the client on the back several times.

B. Perform the Heimlich maneuver. Rationale: The client cannot talk, coughs only once, and is demonstrating the universal choking sign: grasping at the throat with the hands. Choking requires immediate intervention. The Heimlich maneuver is the most effective method for clearing the obstruction in the airway of a choking person.

A nurse in the emergency department is caring for a client who collapsed after playing football on a hot day. After reviewing the admission laboratory findings, the nurse recognizes that these findings are consistent with which of the following conditions? Sodium 152 mEq/L Glucose 102 mg/dLPotassium 3.6 mEq/L BUN 18 mg/dLChloride 105 mEq/L Creatinine 0.7 mg/dL A. Renal failure B. Low-protein diet C. Dehydration D. Syndrome of inappropriate antidiuretic hormone (SIADH)

C. Dehydration Rationale: Hypernatremic (hypertonic) dehydration occurs with excessive fluid losses due to perspiration, respiration, and inadequate fluid intake. The nurse should note that the client's sodium is above the accepted reference range, while glucose, potassium, BUN, chloride, and creatinine are within the accepted reference ranges. The client's history, collapsing after activity on a hot day, and the sodium findings are consistent with dehydration due to water deficit.

A nurse is caring for an older adult client who states, "I am afraid that I may fall while walking to the bathroom during the night." Which of the following actions should the nurse take? A. Limit the client's fluid intake in the evening. B. Obtain a bedside commode for the client's use. C. Leave a nightlight on in the client's room. D. Put the side rails up and tell the client to call the nurse before voiding.

C. Leave a nightlight on in the client's room. Rationale: This is an appropriate action for keeping the client safe. Night vision may be impaired in older adult clients. If the client awakens in the night, a nightlight may help the client to recognize the surroundings, decreasing the likelihood of disorientation. It will also help to decrease the possibility of a fall on the way to the bathroom because the path will be illuminated and the client will be less likely to trip over objects in the room.

A nurse accidentally administers the wrong medication to a client, which results in a severe allergic reaction and prolongs the client's hospitalization. The client could rightfully sue the nurse for which of the following? A. Battery B. Assault C. Malpractice D. Abuse

C. Malpractice Rationale: The client could sue the nurse for malpractice, which is the failure to meet the standard of conduct another professional would exercise in similar circumstances and that failure causes harm. This nurse has made an error that harmed the client.

A nurse is caring for a client who needs a stool specimen collected. Which of the following actions should the nurse take when obtaining the specimen? A. Use a sterile swab to obtain the specimen. B. Place the specimen in a sterile container. C. Label the paper bag in which specimen container is placed. D. Send specimen container immediately to the lab.

D. Send specimen container immediately to the lab. Rationale: The nurse should label the specimen contain and send it immediately to the laboratory. A delay in transport can result in altered laboratory findings.