A nurse is preparing to infuse a 250-mL unit of packed red blood cells (RBCs) over 2 hours.

The drop factor of the manual intravenous (IV) tubing is 15 drops/mL. How many drops per minute should the nurse adjust the flow rate to deliver?

Answer and Explanation

The Correct Answer is ["31"]

Step 1: Calculate the total volume to be infused. Total volume = 250 mL.

Step 2: Calculate the total time for the infusion in minutes. Total time = 2 hours × 60 minutes/hour = 120 minutes.

Step 3: Calculate the flow rate in mL/min. Flow rate = Total volume ÷ Total time = 250 mL ÷ 120 min = 2.08 mL/min.

Step 4: Calculate the flow rate in drops/min. Flow rate = 2.08 mL/min × 15 drops/mL = 31.25 drops/min. So, the nurse should adjust the flow rate to deliver approximately 31 drops per minute.

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Correct Answer is A

Explanation

Choice A rationale

A purplish-colored stoma may indicate compromised circulation, which is a serious condition that requires immediate medical attention18.

Choice B rationale

A rosebud-like stoma orifice is a normal finding and does not need to be reported18.

Choice C rationale

A stoma oozing red drainage is a normal finding immediately after surgery and does not need to be reported18.

Choice D rationale

A shiny, moist stoma is a normal finding and does not need to be reported18.

A. Use soap to clean the patient’s skin. B. Apply a barrier cream to the patient’s skin. C. Avoid applying friction when drying the patient’s skin. D. Use warm water to clean the patient’s skin.

Correct Answer is ["B","C","D"]

Explanation

Choice A rationale

Using soap to clean the patient’s skin is not the best practice. Soap can dry out and irritate the skin, especially in patients with urinary incontinence. It can disrupt the skin’s natural pH balance and make it more susceptible to damage.

Choice B rationale

Applying a barrier cream to the patient’s skin is a recommended practice. Barrier creams provide a protective layer on the skin that can help prevent irritation from urine. They can also help to keep the skin moisturized, which is important for maintaining skin integrity.

Choice C rationale

Avoiding friction when drying the patient’s skin is crucial. Friction can cause further damage to the skin, especially in areas that are already irritated or broken down due to incontinence. It’s recommended to gently pat the skin dry rather than rubbing it.

Choice D rationale

Using warm water to clean the patient’s skin is a good practice. Warm water is less irritating to the skin than hot water and can help to cleanse the area without causing additional discomfort or damage.

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A nurse is preparing to infuse a 250-mL unit of packed red blood cells (RBCs) over 2 hours. The drop factor of the manual intravenous (IV) tubing is 15 drops/mL. How many drops per minute should the nurse adjust the flow rate to deliver?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a post-anesthesia care unit (PACU) is assessing a patient who has a newly created colostomy. What findings should the nurse report to the provider?

Correct Answer is A

Explanation

A nurse is providing skin care for a patient with urinary incontinence. What actions should the nurse take?

Correct Answer is ["B","C","D"]

Explanation

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A nurse is preparing to infuse a 250-mL unit of packed red blood cells (RBCs) over 2 hours.

The drop factor of the manual intravenous (IV) tubing is 15 drops/mL. How many drops per minute should the nurse adjust the flow rate to deliver?