The nurse began an infusion at 1245 per healthcare directive. The order reads, "Infuse NS 750 mL over 4 hours at a rate of 100 mL/hr. If the client's systolic blood pressure remains below 90 mmHg for more than 30 minutes, page me stat." If the nurse discontinues the infusion at 1545, how many milliliters should remain in the solution set?

Answer and Explanation

The Correct Answer is ["450"]

Time from 1245 to 1545 = 3 hours
Infused amount = 3 × 100 = 300 mL

Thus, remaining fluid =
750 mL (ordered total) – 300 mL = 450 mL

Answer: 450 mL should remain in the solution set.

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Correct Answer is B

Explanation

A. While tracking intake and output is important, it does not directly address the patient’s current complaint or help identify urinary retention.
B.The first action is to assess the bladder for distention by palpating above the symphysis pubis. This helps determine if the bladder is full and not emptying, which may indicate urinary retention.
C. Encouraging natural voiding techniques (like running water) is appropriate, but only after assessment confirms the bladder is not overly distended.
D. Notifying the provider is important if interventions fail, but the nurse should first assess before escalating the situation.

A. Informing the surgeon of the situation B. Asking the circulating nurse to look for the sponge C. Looking on the instrument table for the sponge D. Recording that the count was incorrect

Correct Answer is A

Explanation

A. The priority action when a sponge count is incorrect is to immediately notify the surgeon before closing the surgical site. Retained surgical items like sponges can lead to serious complications, including infection and the need for further surgery. Prompt communication ensures patient safety.
B. Although helpful, this is a secondary step. The surgeon must be informed immediately to halt closure and assist in locating the missing sponge.
C. Searching is appropriate, but it should be done after informing the surgeon. Delaying notification risks closure with a retained item.
D. Documentation is important after resolution. It is not the first action in response to a missing sponge during surgery.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What would the nurse anticipate to be used to treat this imbalance? Your patient had a Foley catheter removed four hours ago, but reports the inability to void with a subjective sensation of needing to urinate. Which action should the nurse perform FIRST? Select one:

Correct Answer is B

Explanation

A surgeon is performing an abdominal hysterectomy. Before the surgery is completed, the operating room nurse counts the sponges and notes that the sponge count is not correlating with the preoperative count. Which action by the nurse is important?

Correct Answer is A

Explanation

The chronic inflammatory disease that involves all layers of the intestinal tract and commonly affects the distal ileum and proximal colon is called:

The patient diagnosed with thrombocytopenia is at risk for which of the following adverse effects: Select one:

The nurse has a prescription to administer furosemide (Lasix) 30 mg orally twice daily. On hand is furosemide 40mg per 5 mL oral solution. How many milliliters should the nurse administer in a 24-hour period? Round one place to the right of the decimal.

A surgeon is performing an abdominal hysterectomy. Before the surgery is completed, the operating room nurse counts the sponges and notes that the sponge count is not correlating with the preoperative count. Which action by the nurse is important?

A nurse is monitoring a client who had a kidney biopsy for postoperative complications. The nurse understands that the client is at risk for which potential serious complication? Select one:

The client is to receive spironolactone 150 mg daily. How many tablets, per dose, should the nurse administer if spironolactone 50 mg tablets are available? Round to the nearest whole number.

A patient tells the oncology nurse about an upcoming vacation to the beach to celebrate completing radiation treatments for cancer. What response by the nurse is most appropriate? Select one:

A nurse is reinforcing dietary instructions with a client who has episodes of biliary colic from chronic cholecystitis. Which of the following diets should the nurse reinforce in the teaching plan?