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A client has received a prescription for a fluid bolus of 0.9% sodium chloride, 200 mL to be infused in 30 minutes. How many mL/hr should the nurse program the infusion pump to deliver? (Please enter the numerical value only.)

The question is asking for the rate at which the infusion pump should be programmed to deliver a fluid bolus of 200 mL in 30 minutes. This can be calculated using the formula for rate which is volume divided by time.

Answer and Explanation

The Correct Answer is ["400"]

Step 1: Convert the volume of fluid to be infused from mL to L (since the rate is usually measured in mL/hr):

200 mL = 200 mL (No conversion needed as the volume is already in mL)

Step 2: Convert the time for infusion from minutes to hours (since the rate is usually measured in mL/hr):

30 minutes = 30 ÷ 60 = 0.5 hours

Step 3: Calculate the rate (volume ÷ time):

Rate = Volume ÷ Time

Rate = 200 mL ÷ 0.5 hours

Rate = 400 mL/hr

The nurse should program the infusion pump to deliver at a rate of 400 mL/hr.

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Correct Answer is C

Explanation

Choice A reason: While obtaining a urine specimen is important for diagnosing infection, it does not address the immediate discomfort and potential urinary retention the client may be experiencing.

Choice B reason: Cleansing the glans penis is part of good hygiene but does not address the client's symptoms of a full bladder and weak urine flow.

Choice C reason: Palpating for suprapubic distention can provide immediate information about bladder fullness and potential urinary retention, which may require prompt intervention.

Choice D reason: Maintaining a voiding diary is useful for tracking symptoms over time but does not provide an immediate assessment or intervention for the client's current symptoms.

A. Prepare for a cesarean delivery B. Administer calcium gluconate C. Obtain blood pressure D. Stop infusion of magnesium E. Increase IV fluids F. Administer oxygen G. Obtain serum magnesium level H. Make preparations to prevent cardiac arrest

Correct Answer is ["B","C","F","G","H"]

Explanation

Choice A reason: Preparing for a cesarean delivery is not indicated solely based on the information provided. The patient is at 36 weeks with moderate pre-eclampsia and there are no immediate signs of fetal distress or a need for emergency delivery based on the nurse’s notes.
Choice B reason: Administering calcium gluconate is appropriate if there are signs of magnesium sulfate toxicity, as it acts as an antidote. The patient’s decreased level of consciousness and absent DTRs may suggest magnesium toxicity, making this a correct intervention.
Choice C reason: Obtaining blood pressure is a standard and ongoing requirement for monitoring a pre-eclampsia patient, especially after noting a significant drop in blood pressure from 170/98 mm Hg to 118/78 mm Hg, which could indicate an overcorrection or other issues.
Choice D reason: Stopping the infusion of magnesium sulfate is not indicated at this time. While the patient’s decreased LOC and absent DTRs are concerning, magnesium sulfate is critical for preventing seizures in pre-eclampsia and should not be stopped without clear signs of overdose and physician consultation.
Choice E reason: Increasing IV fluids is not indicated and could be harmful. The patient already has pulmonary edema and increasing fluids could exacerbate this condition, especially in the context of pre-eclampsia where fluid management needs to be carefully balanced.
Choice F reason: Administering oxygen is correct as the patient’s oxygen saturation has dropped from 98% to 93%, and the goal is to maintain it above 96% as per the physician’s orders.
Choice G reason: Obtaining serum magnesium level is correct because it is necessary to monitor for signs of magnesium sulfate toxicity given the patient’s symptoms of decreased LOC and absent DTRs.
Choice H reason: Preparing to prevent respiratory or cardiac arrest is correct as the patient has signs that may suggest impending magnesium sulfate toxicity, which can lead to respiratory depression or cardiac arrest.

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Naxlex Comprehensive Predictor Exams

An older adult male client arrives at the clinic reporting that his bladder always feels full. The client also reports a weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating the urine stream. Which action should the nurse implement?

Correct Answer is C

Explanation

Patient Data Exhibits The nurse reviews the assessment findings along with the physician orders. Which immediate interventions would the nurse initiate? Select all that apply.

Correct Answer is ["B","C","F","G","H"]

Explanation

Patient Data Exhibits Which interventions are indicated to promote positive outcomes for the patient? Select all that apply.

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