A nurse is preparing to administer potassium chloride 10 mEq IV over 1 hr to a client. Available in potassium chloride 10 mEq in 100 mL of 0.9% sodium chloride. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.).

10 mL/hr.

50 mL/hr.

100 mL/hr.

500 mL/hr.

Answer and Explanation

The Correct Answer is C

Choice A rationale:
10 mL/hr would be the correct infusion rate if the client was receiving the entire 10 mEq of potassium chloride in a 100 mL solution over 1 hour. However, the question asks for the rate at which to administer 10 mEq over 1 hour, which means the total volume should be 100 mL/hr.
Choice B rationale:
50 mL/hr would be the correct infusion rate if the client was receiving the entire 10 mEq of potassium chloride in a 100 mL solution over 2 hours. However, the question specifies 1 hour, so the rate should be higher.
Choice C rationale:
This is the correct answer. To administer 10 mEq of potassium chloride in 100 mL over 1 hour, the infusion pump should be set to deliver 100 mL/hr.
Choice D rationale:
500 mL/hr would be the correct infusion rate if the client was receiving the entire 10 mEq of potassium chloride in a 100 mL solution over 10 minutes (1/6th of an hour). However, the question specifies 1 hour, so the rate should be much lower.

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Correct Answer is C

Explanation

Choice A rationale:
Having the client point their chin upward to swallow is not a recommended action to reduce the risk of aspiration. In fact, this action can increase the risk of choking and aspiration, as it may cause food or liquids to enter the airway.
Choice B rationale:
Offering the client saltine crackers between meals is not a suitable action for reducing the risk of aspiration. Saltine crackers are dry and can be challenging to swallow for someone with dysphagia, potentially increasing the risk of aspiration.
Choice C rationale:
Thicken liquids before serving is the correct action to reduce the risk of aspiration in a client with dysphagia. Thickened liquids are easier to swallow and less likely to enter the airway, reducing the risk of aspiration pneumonia.
Choice D rationale:
Placing food on the affected side of the mouth does not address the risk of aspiration directly. Dysphagia may affect both sides of the mouth, and placing food on one side does not ensure safe swallowing and reduces the effectiveness of addressing the problem.

A. Papilledema. B. Halo sign. C. Racoon's eyes. D. Elevated WBCs.

Correct Answer is B

Explanation

Choice A rationale:
Papilledema refers to swelling of the optic disc in the eye, which can occur due to increased intracranial pressure. While it may be present in cases of basilar skull fracture, it is not a reliable finding for determining the discharge of cerebrospinal fluid (CSF).
Choice B rationale:
The halo sign is a reliable finding for determining that the nasal discharge is cerebrospinal fluid. The halo sign is characterized by a ring of blood surrounded by a clear or yellowish fluid (CSF) on a dressing or tissue. This occurs because blood from the fracture mixes with the clear CSF, creating a distinct appearance.
Choice C rationale:
Racoon's eyes, also known as periorbital ecchymosis, is a term used to describe bruising around the eyes. While it can be seen in basilar skull fractures, it is not specific to cerebrospinal fluid leakage and, therefore, not reliable for identifying the nasal discharge as CSF.
Choice D rationale:
Elevated white blood cells (WBCs) in the nasal discharge can indicate infection, inflammation, or an immune response. However, it does not provide direct evidence that the discharge is cerebrospinal fluid, so this is not a reliable finding for determining the nature of the nasal discharge in this context.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has dysphagia following a stroke. Which of the following actions should the nurse take to reduce the risk of aspiration?

Correct Answer is C

Explanation

A nurse in an emergency department is assessing a client who has a basilar skull fracture and serosanguineous nasal discharge following a motor vehicle crash. Which of the following findings should the nurse identify as reliable for determining that the discharge is cerebrospinal fluid?

Correct Answer is B

Explanation

A nurse is caring for a client who had moderate sedation during a procedure. The client's airway is obstructing, and they have an oxygen saturation of 90%. Which of the following interventions is the first action the nurse should take?

A nurse in an emergency department is caring for a client who is in a sickle cell crisis. Which of the following actions should the nurse take?(Select all that apply.).

A nurse educator is teaching a newly licensed nurse about strategies to reduce the risk of infection in the client care area. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

A nurse is preparing to administer enoxaparin 0.75 mg/kg subcutaneously to a client who weighs 154 lb. The amount available is enoxaparin 60 mg/0.6 mL. How many mL should the nurse administer?(Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.).

A nurse in the emergency department is preparing to irrigate the eyes of a client who received a chemical splash on their face. Which of the following actions should the nurse take?

A home health nurse is inspecting a client's residence for electrical hazards as part of the agency's quality improvement plan. Which of the following findings should the nurse identify as a safety hazard?

A nurse is providing teaching to a female client who has herpes simplex virus type 2. Which of the following client statements indicates an understanding of the teaching?