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One liter of normal saline is to infuse over 8 hours. At what rate will the nurse set the infusion pump?

Answer and Explanation

The Correct Answer is ["125"]

Calculation Steps

Step 1: Convert 1 liter to milliliters (mL).

1 liter = 1000 mL

Result: 1000 mL

Step 2: Determine the total time in hours.

Total time = 8 hours

Result: 8 hours

Step 3: Calculate the infusion rate in milliliters per hour (mL/hr).

Infusion rate = Total volume (mL) ÷ Total time (hours)

Step 4: Perform the division.

1000 mL ÷ 8 hours = 125 mL/hr

Result: 125 mL/hr

Therefore, the nurse should set the infusion pump to 125 mL/hr.

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Correct Answer is A

Explanation

a. Several visits of the same child with varied injuries.

Explanation of Choices

Choice A Reason: Several Visits of the Same Child with Varied Injuries

This scenario raises the highest suspicion of child abuse. Multiple visits with different injuries can indicate a pattern of harm rather than isolated accidents. Healthcare providers are trained to recognize that varied injuries over time, especially in different stages of healing, can be a red flag for abuse. This pattern suggests that the child may be experiencing ongoing harm rather than a single incident. The nurse should conduct a thorough assessment and consider involving child protective services to ensure the child’s safety.

Choice B Reason: A 5-Year-Old Child Who Broke His Arm and Clings to Mother Crying

While a broken arm in a child can be concerning, it is not uncommon for children to sustain such injuries during play or accidents. The child’s emotional response of clinging to the mother and crying is also typical for a young child in pain and distress. This scenario alone does not strongly indicate abuse without additional context or evidence. However, the nurse should still assess the situation carefully and consider any other signs or patterns that might suggest abuse.

Choice C Reason: A 1-Year-Old Child Who Has a Dislocated Shoulder from Arm Swinging

A dislocated shoulder in a 1-year-old is unusual and can be concerning. While it could result from an accident, such as arm swinging, it is also a potential sign of abuse, especially if the explanation does not match the injury. The nurse should investigate further, considering the child’s medical history and any other signs of potential abuse. However, this scenario alone does not provide as strong an indication of abuse as multiple varied injuries.

Choice D Reason: Repeated Visits of the Same Child with Middle Ear Infections

Repeated visits for middle ear infections are common in young children and are typically related to medical issues rather than abuse. Middle ear infections can occur frequently in children due to their anatomy and immune system development. This scenario does not raise immediate concerns about abuse unless there are other signs or patterns of harm. The nurse should focus on providing appropriate medical care and monitoring the child’s health.

A. The CAGE Questionnaire B. The Abnormal Involuntary Movement Scale C. The Clinical Institute Withdrawal Assessment Scale D. Refer the client for physician evaluation

Correct Answer is A

Explanation

a. The CAGE Questionnaire

Explanation of Choices

Choice A Reason: The CAGE Questionnaire

The CAGE Questionnaire is a widely used screening tool for identifying potential alcohol use disorders. It consists of four questions that focus on key aspects of alcohol dependency: Cutting down, Annoyance by criticism, Guilty feelings, and Eye-openers (drinking first thing in the morning). This tool is quick to administer and has been validated in various clinical settings, making it an effective choice for initial screening of alcohol problems. The CAGE Questionnaire is particularly useful in preoperative assessments to identify patients who may be at risk for alcohol-related complications during and after surgery.

Choice B Reason: The Abnormal Involuntary Movement Scale

The Abnormal Involuntary Movement Scale (AIMS) is used to assess the severity of tardive dyskinesia and other involuntary movements, typically in patients taking antipsychotic medications. It is not designed to screen for alcohol use disorders. Therefore, it would not be appropriate for evaluating a client suspected of having a drinking problem.

Choice C Reason: The Clinical Institute Withdrawal Assessment Scale

The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) is a tool used to assess the severity of alcohol withdrawal symptoms. While it is valuable for managing patients already known to have alcohol dependence, it is not a primary screening tool for identifying alcohol use disorders. The CIWA-Ar is more appropriate for monitoring patients during detoxification rather than initial screening.

Choice D Reason: Refer the Client for Physician Evaluation

Referring the client for a physician evaluation is a reasonable step if the nurse suspects a drinking problem. However, using a validated screening tool like the CAGE Questionnaire can provide immediate, actionable information that can guide the next steps in care. The CAGE Questionnaire can help determine the severity of the problem and whether a referral to a specialist is necessary.

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One liter of normal saline is to infuse over 8 hours. At what rate will the nurse set the infusion pump?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Several children come to the Emergency Department for treatment. The situation that would cause the nurse to have the highest suspicion of child abuse would be:

Correct Answer is A

Explanation

The nurse believes that a client being admitted for a surgical procedure may have a drinking problem. Which screening tool should the nurse use to further evaluate this possibility?

Correct Answer is A

Explanation

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