A client is to receive 250 mL of IV fluid over 90 minutes by gravity.

The drop factor on the IV tubing is 20 gtts/mL. How many gtts/min should be administered?

Answer and Explanation

The Correct Answer is ["56"]

Step 1 is (250 mL ÷ 90 min) × 20 gtt/mL.

Step 2 is (2.777 mL/min × 20 gtt/mL).

Step 3 is 55.55 gtts/min. The final calculated answer is 56 gtts/min.

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Correct Answer is C

Explanation

Choice A rationale

Childhood memory recall reflects cognitive functioning but is unrelated to the patient's rehabilitation involvement, which focuses on regaining lost functional capacities following injury. Such a goal lacks immediate functional relevance.

Choice B rationale

Returning to work as a corporate attorney may be an eventual aim but depends on higher cognitive recovery levels and is too specific. Early rehabilitation outcomes focus on participation in the recovery process.

Choice C rationale

Active participation indicates readiness and willingness to engage in therapies essential for regaining lost functions. It aligns with goals for a transition from acute care to rehabilitation emphasizing functional improvement.

Choice D rationale

Motor coordination improvements require therapy timelines extending beyond two weeks. Such a rigid short-term goal undermines individualized rehabilitation focusing on measurable progress over more realistic durations.

A. Can squeeze the nurse's hand upon verbal request. B. Follows simple commands with repetition/prompting from nurse. C. Has purposeful movement when the nurse rubs the sternum. D. Extends upper and lower extremities in response to painful stimuli.

Correct Answer is D

Explanation

Choice A rationale

Squeezing the nurse’s hand on verbal request suggests neurological improvement and does not warrant urgent intervention, indicating preserved motor response and cognition.

Choice B rationale

Following commands with repetition/prompting shows mild cognitive delay or reduced processing but does not represent deterioration or life-threatening concern needing immediate action.

Choice C rationale

Purposeful movement to sternal rub implies intact motor response to noxious stimuli. It does not indicate significant neurologic worsening requiring urgent intervention.

Choice D rationale

Extending extremities in response to painful stimuli, known as decerebrate posturing, is a severe neurologic deficit indicating brainstem dysfunction and requires immediate nursing intervention.

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A client is to receive 250 mL of IV fluid over 90 minutes by gravity. The drop factor on the IV tubing is 20 gtts/mL. How many gtts/min should be administered?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient who had a serious head injury.The patient has recovered enough to be transferred to a rehabilitation facility.Which of the following rehabilitation goals would be most appropriate for the patient?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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A client is to receive 250 mL of IV fluid over 90 minutes by gravity.

The drop factor on the IV tubing is 20 gtts/mL. How many gtts/min should be administered?