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A nurse is preparing to administer cefazolin 1 g by intermittent intravenous (IV) bolus over 30 minutes. Available is cefazolin 1 g in 100 mL dextrose 5% in water (D5W). The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero. Only enter numbers and decimals. Do not enter any letters in your answer.)

Answer and Explanation

The Correct Answer is ["33"]

To calculate the infusion rate, we'll use the following formula:

Infusion rate (gtt/min) = (Volume to be infused (mL) / Time (min)) ) x Drop factor (gtt/mL)

First, calculate the total volume to be infused:

100 mL / 30 min = 3.33 mL/min

Then, multiply the volume per minute by the drop factor:

3.33 mL/min x 10 gtt/mL = 33.3 gtt/min

Therefore, the nurse should set the manual IV infusion to deliver 33 gtt/min.

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Correct Answer is A

Explanation

A. Assessing current anticoagulant use is a priority because t-PA (tissue plasminogen activator) can increase the risk of bleeding, especially if the client has been on anticoagulant medications. It is crucial to determine if there are any contraindications or increased risks for bleeding.
B. While blood pressure control is important, it is secondary to understanding the client's anticoagulant use as it directly affects the safety of t-PA administration.
C. A complete neurologic assessment is important but comes after ensuring there are no contraindications such as recent anticoagulant use that could affect the safety of t-PA.
D. Current treatment for peptic ulcer disease may be relevant for bleeding risks but is not as immediately critical as reviewing anticoagulant use for t-PA safety.

A. Encouraging the client to use a cane as needed for mobility B. Encouraging the client to use their right hand for daily activities C. Encouraging the client to consume a soft diet and thickened liquids D. Encouraging the client to complete all activities of daily living (ADLs) independently

Correct Answer is A

Explanation

A. A client with extreme muscle weakness on the affected side should use a cane or other assistive devices to aid in mobility and ensure safety. This intervention helps the client maintain stability and prevent falls.
B. The client with muscle weakness should use the unaffected hand for daily activities to ensure safety and improve functional outcomes. Using the affected hand may increase the risk of injury.
C. A soft diet and thickened liquids are generally recommended for clients with dysphagia, which is not specifically indicated in the context of muscle weakness due to a stroke.
D. Encouraging the client to complete all ADLs independently may not be feasible or safe due to the muscle weakness. Support and assistance with ADLs are likely needed.

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A client arrives in the emergency department with an ischemic stroke. What is the priority for the nurse to assess in relation to the administration of tissue plasminogen activator (t-PA) as treatment?

Correct Answer is A

Explanation

A nurse is caring for a client who experienced a right-hemispheric stroke and has extreme muscle weakness on the affected side. Which nursing intervention is most appropriate for this client?

Correct Answer is A

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