A nurse is preparing to infuse one unit, 330 mL, of packed red blood cells over 4 hours to a patient with heart failure. The nurse should set the pump to deliver how many mL/hr?

Round to the nearest whole number.

Answer and Explanation

The Correct Answer is ["83"]

To calculate the infusion rate, divide the total volume of fluid to be infused by the total time over which the infusion should occur.

$\frac{330 \text{ mL}}{4 \text{ hours}} = 82.5 \text{ mL/hr}$

Rounding to the nearest whole number, the nurse should set the pump to deliver 83 mL/hr.

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

Explanation

Choice A reason:

Soaking the pin sites with alcohol pads is not recommended as it can dry out the skin and increase the risk of infection. Pin site care typically involves using saline or other recommended solutions to clean the area gently.

Choice B reason:

Removing the vest when bathing the patient is not recommended. The vest provides stability and support for the spinal fracture, and removing it can compromise the patient's safety. Alternative methods should be used to maintain hygiene without removing the vest.

Choice C reason:

Assessing the chest and back for skin breakdown is crucial in patients with a halo device to prevent pressure ulcers and other skin issues. Regular assessment helps identify any potential problems early.

Choice D reason:

Assessing pin sites frequently for signs of infection is essential to prevent complications. Infection at the pin sites can lead to serious issues, and frequent monitoring ensures any signs of infection are caught and treated promptly.

Choice E reason:

Taping a halo wrench to the vest is important for emergencies. The wrench is necessary to quickly remove the halo device if needed in an emergency situation, such as if the patient requires resuscitation.

A. Level of consciousness. B. Focal neurological exam. C. Body posturing. D. Vital signs.

Correct Answer is A

Explanation

Choice A reason:

Assessing the level of consciousness is the most important nursing assessment for detecting early signs of a declining condition in a patient with a severe concussion. Changes in consciousness can indicate worsening brain injury or increased intracranial pressure, and prompt recognition is crucial for timely intervention.

Choice B reason:

A focal neurological exam is important but is more specific to identifying localized neurological deficits rather than detecting general deterioration. It is essential but secondary to monitoring the overall level of consciousness.

Choice C reason:

Body posturing can indicate severe brain injury or increased intracranial pressure, but it typically occurs later in the course of deterioration. Early changes in the level of consciousness are more sensitive indicators of a declining condition.

Choice D reason:

Vital signs are important to monitor, but changes in vital signs can occur later in the progression of a declining neurological status. Early detection of changes in the level of consciousness allows for more timely intervention.

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A nurse is preparing to infuse one unit, 330 mL, of packed red blood cells over 4 hours to a patient with heart failure. The nurse should set the pump to deliver how many mL/hr? Round to the nearest whole number.

Nursing Test Bank

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

Explanation

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Correct Answer is A

Explanation

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A nurse is preparing to infuse one unit, 330 mL, of packed red blood cells over 4 hours to a patient with heart failure. The nurse should set the pump to deliver how many mL/hr?

Round to the nearest whole number.