A client returns to the acute care unit following surgery with 0.9% normal saline infusing at 45 drops/minute through tubing with a drop factor of 60 drops per ml. The postoperative prescriptions include 0.9% normal saline at 75 ml/hour to alternate with Lactated Ringer's solution at 75 ml/hour. An intravenous infusion pump is not available. What action should the nurse implement?

Change the normal saline to a keep open rate until an infusion pump is available.

Increase the rate of the present normal saline infusion to 75 drops per minute.

Leave the normal saline at the current rate until an infusion pump is available.

Switch the saline to Lactated Ringer's solution infusing at 75 drops per minute.

Answer and Explanation

The Correct Answer is C

Choice A: Changing the normal saline to a keep-open rate (KVO) is not appropriate in this situation, as the client has specific fluid orders that need to be followed, and a KVO rate would not provide the prescribed maintenance fluids.

Choice B: Increasing the rate of the present normal saline infusion to 75 drops per minute would not meet the prescription for 0.9% normal saline at 75 ml/hour.

Adjusting the rate this way would require an infusion pump.

Choice C: Leaving the normal saline at the current rate until an infusion pump is available is the most appropriate action. It ensures that the client continues to receive fluids at the ordered rate until the necessary equipment is in place.

Choice D: Switching the saline to Lactated Ringer's solution infusing at 75 drops per minute would not meet the prescribed rate for the normal saline solution. The nurse should follow the specific orders provided.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A: Permanent lifestyle changes may not be necessary for a child with rheumatic fever and associated chorea. Rheumatic fever is typically treated with antibiotics to clear the streptococcal infection and prevent further complications.

Choice B: Muscle tension is not typically decreased with fine motor skill projects, and encouraging such activities may not directly address the symptoms of chorea. Fine motor activities can be pursued if they are enjoyable for the child but should not be presented as a primary treatment.

Choice C: Consistent discipline is important for children but may not be the primary focus when addressing chorea associated with rheumatic fever. Discipline should be appropriate and consistent but should not be the primary intervention for chorea.

Choice D: The chorea or movements are temporary and will eventually disappear. This is the most accurate and reassuring information to provide to the parents. Chorea associated with rheumatic fever typically resolves over time with appropriate treatment, and the child is expected to recover fully.

A. Bladder palpation. B. Blood glucose monitoring. C. Inspection of the mouth. D. Auscultation of breath sounds.

Correct Answer is C

Explanation

Choice A: This is not specifically related to the side effects of phenytoin.

Choice B: This is not directly related to the common side effects of phenytoin, which primarily affect the oral cavity.

Choice C: Phenytoin (Dilantin) is known to cause gingival hyperplasia (enlargement of the gums) as a common side effect. The nurse should regularly inspect the client's mouth to monitor for this adverse effect.

Choice D: This is not specifically relevant to monitoring for phenytoin's side effects.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 6-year-old child is diagnosed with rheumatic fever and demonstrates associated chorea (sudden aimless movements of the arms and legs). Which information should the nurse provide to the parents?

Correct Answer is D

Explanation

What assessment technique should the nurse use to monitor a client for a common untoward effect of phenytoin (Dilantin)?

Correct Answer is C

Explanation

The nurse is helping develop a meal plan based on nutritional guidelines for a 73-year-old client being discharge to home with the client's 65- year-old spouse. Which statement best indicates an understanding of the nutritional guidelines when planning meals by the two spouses?

A client tells the nurse about taking a variety of herbal products, including milk thistle, and has lost about thirty pounds over the last month. Which action should the nurse implement?

A client who has migraine headaches wants to decrease the intake of foods high in tyramine to see if that will reduce the occurrence of headaches. Which food should the nurse recommend that the client eliminate?

An adult client with a diagnosis of bipolar disorder arrives in an elated state on admission to the psychiatric unit. What is the best room assignment the nurse can make for this client?

The nurse instructs a client with Type 2 diabetes mellitus (DM) to avoid refined sugar and carbohydrates. Choosing which food indicates that the client understands the diet teaching?

The practical nurse (PN) palpates a client's radial pulse and notes that the pulse disappears when light pressure is applied. How should the PN document this finding?

The nurse manager of a community mental health treatment facility is establishing a policy for staff members to follow when administering antipsychotic medications. Which standard is most important for the nurse-manager to include in this policy?

When conducting diet teaching for a client diagnosed with hypokalemia, which foods should the nurse encourage the client to eat?