A client receives a prescription for 1 liter of 0.9% sodium chloride, USP intravenously (IV) to be infused over 4 hours. The IV administration set delivers 10 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

Answer and Explanation

The Correct Answer is ["42"]

Step 1: Identify the formula
gtt/min = (Total volume × Drop factor) ÷ Time (in minutes)

Step 2: Insert values
Total volume = 1000 mL, Drop factor = 10 gtt/mL, Time = 4 hr × 60 min/hr = 240 min
gtt/min = (1000 × 10) ÷ 240

Step 3: Calculate
= 10,000 ÷ 240
≈ 41.67

Step 4: Round to the nearest whole number
≈ 42 gtt/min

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Correct Answer is D

Explanation

A. Estimating blood pressure based on the strength or quality of the radial pulse is not a reliable method. Pulse volume can provide only a very rough sense of perfusion but does not give a numeric measurement of systolic or diastolic pressure. Relying on this method could lead to inaccurate assessment, delayed recognition of hypotension or hypertension, and inappropriate clinical interventions, putting the client at risk.

B. While it is essential to document the limitations in obtaining vital signs, documentation alone does not resolve the issue. The client still needs accurate and timely blood pressure measurements for safe monitoring and care, especially if they have a condition that could compromise hemodynamic stability. Simply recording that measurement is not possible fails to meet the standard of care.

C. Using a previous blood pressure reading is unsafe because it does not reflect the client’s current condition. Vital signs can change rapidly due to fluid shifts, pain, medications, or other medical issues. Documenting an old reading can mislead the care team and result in inappropriate interventions or delayed response to changes in the client’s status.

D. This is the most appropriate and safe action. When the upper extremities are unavailable due to casts or injury, alternative validated sites, such as the popliteal artery, should be used. The nurse can teach the UAP how to position the client correctly, flexing the knee while supine, to allow proper cuff placement and accurate measurement. This ensures the client receives safe and reliable monitoring, and the staff is competent in using alternative techniques when standard sites are inaccessible.

A. Ulcerative colitis. B. Irritable bowel syndrome. C. Lactose intolerance. D. Diverticulitis.

Correct Answer is C

Explanation

A. Ulcerative colitis is an inflammatory bowel disease that primarily affects the colon and rectum, causing symptoms such as diarrhea, rectal bleeding, and abdominal pain. While diet can influence symptoms, lactose-containing foods specifically triggering bloating and cramps is not a hallmark feature of ulcerative colitis.

B. Irritable bowel syndrome (IBS) can cause bloating, abdominal pain, and changes in bowel habits. However, IBS symptoms are not consistently triggered by lactose-containing foods; triggers vary widely among individuals. Therefore, while IBS is possible, the specificity of symptoms after dairy intake points elsewhere.

C. Lactose intolerance is the most likely condition. Lactose intolerance occurs when the body lacks sufficient lactase, the enzyme needed to digest lactose in milk and dairy products. Common symptoms include bloating, abdominal cramps, diarrhea, and gas after consuming foods like ice cream and cheese, matching the client’s reported symptoms.

D. Diverticulitis involves inflammation of diverticula in the colon, causing left lower quadrant abdominal pain, fever, and sometimes constipation or diarrhea. Symptoms are not specifically triggered by dairy intake, making this diagnosis less likely in this scenario.

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Naxlex Comprehensive Predictor Exams

The unlicensed assistive personnel (UAP) reports that a client's blood pressure cannot be measured in the arms because the client has casts on both arms and is unable to be measured in the legs because the client is in the supine position. Which action should the nurse implement?

Correct Answer is D

Explanation

A client reports bloating and abdominal cramps after eating ice cream and foods with cheese. Which condition should the nurse suspect?

Correct Answer is C

Explanation

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