Nursing Elites

1. In hanging a parenteral IV fluid that is to be infused by gravity, rather than with an infusion pump, the nurse notes that the IV tubing is available in different drop factors. Which tubing is a microdrop set?

• A. 15 drops per milliliter
• B. 60 drops per milliliter
• C. 20 drops per milliliter
• D. 10 drops per milliliter

Correct answer: B

Rationale: A microdrop set delivers 60 drops per milliliter of IV fluid. This allows for a more precise control of the infusion rate. The correct choice is B because it provides the desired microdrop rate. Choices A, C, and D are incorrect. A delivers 15 drops per milliliter, which is a macrodrop set. C delivers 20 drops per milliliter, also a macrodrop set. D delivers 10 drops per milliliter, another macrodrop set. Therefore, the correct choice for a microdrop set is B.

2. The schizophrenic client who is admitted to the hospital for possible bowel obstruction has an NG tube and complains of pain. What should the nurse do at this time?

• A. Decrease the stimuli and observe frequently
• B. Administer the PRN sedative
• C. Call the physician immediately
• D. Administer the PRN pain medication

Correct answer: D

Rationale: In this scenario, the nurse should administer the PRN (as needed) pain medication to address the schizophrenic client's complaint of pain. It is essential to provide relief and comfort to the client experiencing pain. Option A, decreasing stimuli and observing frequently, may not address the underlying cause of pain and delay relief. Option B, administering a sedative, does not target the pain but may mask symptoms. Option C, calling the physician immediately, while important in some situations, is not the most immediate action needed to alleviate the client's pain. Therefore, the most appropriate action at this time is to administer the PRN pain medication to help alleviate the client's discomfort.

3. Clomiphene is prescribed for a female client to treat infertility. The nurse is providing information to the client and her spouse about the medication and provides the couple with which information?

• A. If the oral tablets are not successful, the medication will be administered intravenously.
• B. The couple should engage in coitus at least every other day during treatment.
• C. The physician should be notified immediately if breast engorgement occurs.
• D. Multiple births occur in a small percentage of clomiphene-facilitated pregnancies.

Correct answer: D

Rationale: The correct answer is that multiple births (usually twins) occur in a small percentage (8% - 10%) of clomiphene-facilitated pregnancies. The couple should be informed about this potential outcome. Clomiphene is available in 50-mg tablets for oral use; there is no intravenous form of the medication. Breast engorgement is a common side effect of clomiphene that typically resolves after discontinuation of the medication. Ovulation usually happens 5 to 10 days after the last dose of clomiphene, and the couple is advised to engage in coitus at least every other day during this time. Therefore, choices A, B, and C are incorrect as they do not provide accurate information regarding clomiphene treatment for infertility.

4. The nurse observes a nursing assistant performing AM care for a client with a new leg cast. Which action by the assistant will the nurse intervene?

• A. Lifting the affected leg with the palms of the hands
• B. Covering the affected leg with a blanket to avoid chills
• C. Placing plastic over the groin prior to bathing
• D. Elevating the casted leg on two pillows

Correct answer: B

Rationale: The correct answer is to intervene when the assistant covers the affected leg with a blanket to avoid chills. A new cast should not be covered to allow the heat from the cast to evaporate, preventing complications. Lifting the affected leg with the palms of the hands is appropriate for proper handling. Placing plastic over the groin prior to bathing is a standard practice to protect the client's privacy and maintain hygiene. Elevating the casted leg on two pillows helps reduce swelling and promote circulation, making it a suitable action.

5. What should the nurse do while caring for a client with an eating disorder?

• A. Encourage the client to cook for others
• B. Weigh the client daily and keep a journal
• C. Restrict access to mirrors
• D. Monitor food intake and behavior for one hour after meals

Correct answer: D

Rationale: The correct answer is to monitor food intake and behavior for one hour after meals. This is crucial in caring for a client with an eating disorder as it helps in assessing any immediate risks related to the disorder. Option A is incorrect as it may trigger additional stress for the client and distract from the main focus of managing the disorder. Option B, weighing the client daily, could lead to an unhealthy focus on weight and potentially worsen the client's mental health. Option C, restricting access to mirrors, although it may be beneficial for body image concerns, does not directly address the core issue of monitoring food intake and behavior, which is essential in managing eating disorders.

Similar Questions