A client is receiving IV fluids at 100 ml per hour. The nurse is told in report at 1200 that there are 500 ml left in the bag. At what time should the nurse expect to hang a new bag?

Report the time in military time.

Answer and Explanation

The Correct Answer is ["1700"]

To calculate the time when a new IV bag will be needed, we can divide the total volume left in the bag by the infusion rate.

With 500 ml remaining and an infusion rate of 100 ml per hour, it will take 5 hours for the current bag to be depleted.

Since the report was given at 1200 (which is noon in military time), adding 5 hours brings us to 1700, or 5:00 PM.

Therefore, the nurse should expect to hang a new IV bag at 1700 hours in military time.

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Correct Answer is ["A","B","C","E"]

Explanation

A. Clients with dementia often experience cognitive decline, which can affect their ability to navigate their surroundings safely. Modifying the environment can include simplifying the layout, reducing clutter, using clear signage, and ensuring adequate lighting to enhance orientation and reduce confusion.

B. Communication difficulties are common in dementia. Using short, simple sentences helps clients better understand instructions and information. It reduces confusion and frustration, promoting effective communication and cooperation during care.

C. Maintaining independence and dignity is crucial for clients with dementia. Allowing them to participate in Activities of Daily Living (ADLs) to the extent possible helps preserve their functional abilities, boosts their self-esteem, and promotes a sense of control over their environment.

E. Providing choices within a structured framework can empower clients with dementia. It allows them to maintain some control over their daily routine and decisions, thereby enhancing their sense of autonomy and reducing agitation or resistance to care.

D. This is not an appropriate intervention. Social interaction, including visits from family members, can have significant emotional and psychological benefits for clients with dementia. It can help reduce feelings of isolation, improve mood, and provide reassurance and familiarity.

A. Establish a trusting nurse-client relationship. B. Identify the client's belief in a Supreme Being. C. Tell the client everything will be fine when they get home. D. Have the client describe the physical problem.

Correct Answer is A

Explanation

A. Establishing a trusting relationship is crucial in nursing care, including when addressing spiritual distress. This intervention allows the nurse to create a safe space for the client to express their feelings, concerns, and spiritual beliefs. It fosters open communication and helps the nurse understand the depth of the client's distress, which is essential for providing effective support and care.

B. Understanding the client's belief system, including their beliefs in a Supreme Being or higher power, is important in addressing spiritual distress. This information helps the nurse provide culturally and spiritually sensitive care that aligns with the client's values and preferences. However, while important, this would typically follow establishing a trusting relationship as it involves a deeper understanding of the client's spiritual perspective.

C. This response may come from a well-intentioned desire to reassure the client, but it oversimplifies the client's concerns and does not address the root of spiritual distress. Spiritual distress is often complex and may involve existential questions, fears, or conflicts related to beliefs, meaning, and purpose.

Offering simplistic reassurances without addressing these deeper issues may not effectively alleviate the client's distress.

D. Spiritual distress is distinct from physical problems, although it can manifest with physical symptoms. Focusing solely on the physical aspects may overlook the spiritual and existential concerns that underlie the client's distress. While it's important to assess physical symptoms comprehensively, this approach does not directly address the spiritual distress identified by the nurse.

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A client is receiving IV fluids at 100 ml per hour. The nurse is told in report at 1200 that there are 500 ml left in the bag. At what time should the nurse expect to hang a new bag? Report the time in military time.

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Naxlex Comprehensive Predictor Exams

The nurse is providing care for an elderly client who has dementia. Interventions used would include: (SELECT ALL THAT APPLY)

Correct Answer is ["A","B","C","E"]

Explanation

The nurse assesses that a client is experiencing spiritual distress. What should be the nurse's primary intervention?

Correct Answer is A

Explanation

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A client is receiving IV fluids at 100 ml per hour. The nurse is told in report at 1200 that there are 500 ml left in the bag. At what time should the nurse expect to hang a new bag?

Report the time in military time.