A nurse observes an assistive personnel (AP) empty an indwelling urinary catheter drainage bag while not wearing gloves. Which of the following interventions should the nurse take first?

Provide the AP with a copy of the unit's policy.

Notify the charge nurse about the incident.

Talk with the AP about the technique used.

Conduct an in-service on standard precautions.

Answer and Explanation

The Correct Answer is C

A.   Providing the AP with a copy of the unit's policy may be done but is not the first step. Direct communication is important for immediate feedback.
B.   Notifying the charge nurse is appropriate but may not be the first action when direct communication with the AP can address the issue.
C.   Talking with the AP about the technique used is the first and immediate action to address the observed lapse in infection control practices.
D.   Conducting an in-service on standard precautions is a broader intervention and may be considered after addressing the immediate concern with the AP.

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Correct Answer is A

Explanation

A. Obtaining apical and radial rates simultaneously allows the nurse to assess for a pulse deficit by comparing the two rates. A pulse deficit is present when the apical rate (heard with a
stethoscope) is greater than the radial rate (palpated at the wrist).

B. Palpating pulses in the lower extremities is not specific for assessing a pulse deficit and may not accurately reflect the cardiac output.

C. Checking blood pressure in left and right arms assesses for blood pressure differences but does not specifically address a pulse deficit.
D. Comparing the pulse strength in the upper extremities does not directly assess for a pulse deficit; simultaneous assessment of apical and radial rates is more appropriate.

Correct Answer is ["150"]

Explanation

The question is about calculating the IV infusion rate for a given solution and volume.

The formula for the infusion rate is: (volume in mL / time in hours) x drop factor in gtts/mL = infusion rate in gtts/min

The drop factor is usually given on the IV tubing package and varies depending on the type of tubing used.

For this question, we can assume a drop factor of 15 gtts/mL, which is common for macrodrip tubing.

Plugging in the numbers, we get: (1200 mL / 8 hr) x 15 gtts/mL = 2250 gtts/hr

To convert from gtts/hr to mL/hr, we divide by the drop factor: 2250 gtts/hr / 15 gtts/mL = 150 mL/hr

Therefore, the nurse should set the IV pump to deliver 150 mL/hr.

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A nurse observes an assistive personnel (AP) empty an indwelling urinary catheter drainage bag while not wearing gloves. Which of the following interventions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a dysrhythmia. Which of the following techniques is appropriate for the nurse to use to assess for a pulse deficit?

Correct Answer is A

Explanation

A nurse is preparing to administer dextrose 5% in 0.45% sodium chloride 1,200 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero is applicable. Do not use a trailing zero.)

Correct Answer is ["150"]

Explanation

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