A nurse and an assistive personnel (AP) are providing care for four clients who were admitted to the medical-surgical unit on the previous shift. The nurse should delegate meal assistance for which of the following clients to the AP?

A client who has Guillain-Barré syndrome

A client who has systemic sclerosis

A client who has amyotrophic lateral sclerosis (ALS)

A client who has a lumbosacral spinal tumor

Answer and Explanation

The Correct Answer is D

Choice A reason:

A client who has Guillain-Barré syndrome: Guillain-Barré syndrome (GBS) can cause significant muscle weakness and paralysis, including the muscles involved in swallowing. Clients with GBS are at high risk for aspiration and may require specialized feeding techniques or assistance from a nurse rather than an AP.

Choice B reason:

A client who has systemic sclerosis: Systemic sclerosis, also known as scleroderma, can affect the esophagus and cause difficulty swallowing. These clients may need careful monitoring and assistance with meals to prevent choking and ensure adequate nutrition.

Choice C reason:

A client who has amyotrophic lateral sclerosis (ALS): ALS affects the motor neurons and can lead to progressive muscle weakness, including the muscles involved in swallowing. Clients with ALS often require specialized feeding techniques and close monitoring during meals to prevent aspiration.

Choice D reason:

A client who has a lumbosacral spinal tumor: A lumbosacral spinal tumor primarily affects the lower back and may cause pain or mobility issues, but it does not typically impair swallowing. Therefore, this client is the most appropriate for the AP to assist with meals, as they are less likely to have complications related to eating.

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Correct Answer is ["100"]

Explanation

Step 1: Identify the infusion rate in mL/hr.

The infusion rate is 100 mL/hr.
= 100 mL/hr.

Step 2: Determine the drop factor for microtubing.

Microtubing has a drop factor of 60 gtt/mL.
= 60 gtt/mL.

Step 3: Calculate the drip rate in gtt/min.

Drip rate (gtt/min) = (Infusion rate in mL/hr) × (Drop factor in gtt/mL) ÷ 60.
Drip rate (gtt/min) = 100 mL/hr × 60 gtt/mL ÷ 60.
= 100 gtt/min.

So, the nurse should set the manual IV infusion to deliver 100 gtt/min.

A. Within 2 days. B. In 3 to 5 days. C. In about 10 days. D. In 6 to 8 days.

Correct Answer is B

Explanation

Choice A reason: While some women may start producing milk as early as 24 to 48 hours after delivery, this is not the typical timeframe for most women. The initial milk produced is colostrum, which is different from the mature milk that comes in later.

Choice B reason: For most women, breast milk “comes in” around 3 to 5 days postpartum. This period marks the transition from colostrum to mature milk, which is more abundant and nutritionally rich. During this time, mothers may experience breast engorgement and increased milk production.

Choice C reason:

Breast milk typically does not take about 10 days to come in. By this time, most women will have already transitioned to mature milk. If milk production has not started by this time, it may indicate a problem that requires medical attention.

Choice D reason:

The timeframe of 6 to 8 days is also not typical for the initial onset of mature milk production. Most women will have their milk come in within the first week postpartum.

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A nurse and an assistive personnel (AP) are providing care for four clients who were admitted to the medical-surgical unit on the previous shift. The nurse should delegate meal assistance for which of the following clients to the AP?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer dextrose 5% in 0.45% sodium chloride IV to infuse at 100 mL/hr. The nurse is using microtubing. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round to the nearest whole number)

Correct Answer is ["100"]

Explanation

A nurse is caring for a client who is postpartum and asks the nurse when her breast milk will “come in.” Which of the following responses should the nurse make?

Correct Answer is B

Explanation

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