The nurse is about to administer 1 liter (1000 mL) of 0.9% NS over 2 hours intravenously to a patient in shock.

What rate should the nurse set on the infusion pump?

Answer and Explanation

The Correct Answer is ["167"]

To calculate the rate for the infusion pump, you would divide the total volume by the total time, then multiply by the drop factor. Here’s how you can do it: Step 1 is: Calculate the total volume in mL, which is 1000 mL.

Step 2 is: Calculate the total time in minutes. Since there are 60 minutes in an hour, 2 hours is 120 minutes.

Step 3 is: Divide the total volume by the total time. So, 1000 mL ÷ 120 min = 8.33 mL/min.

Step 4 is: Multiply the result by the drop factor. If we assume a standard drop factor of 20 drops/mL, then (8.33 mL/min) × 20 drops/mL = 166.67 drops/min. So, the nurse should set the infusion pump to approximately 167 drops per minute. Vital signsVital signs Explore

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Correct Answer is C

Explanation

Choice A rationale
Contractures, or the shortening and hardening of muscles, tendons, or other tissue, can be a complication of burns. However, they are not typically the primary risk for a patient with burns on the head, neck, and chest.
Choice B rationale
While fluid imbalance can occur with any burn due to loss of fluid from the damaged skin, it is not typically the primary risk for a patient with burns on the head, neck, and chest.
Choice C rationale
Airway obstruction is a primary risk for a patient with burns on the head, neck, and chest. Swelling from the burns can lead to obstruction of the airway, making it difficult for the patient to breathe.
Choice D rationale
While infection is a risk with any burn, it is not typically the primary risk for a patient with burns on the head, neck, and chest. The primary risk is airway obstruction due to swelling from the burns.

A. Inform the charge nurse. B. Apply a dressing under the client’s nose. C. Check the client’s temperature. D. Test the drainage for glucose.

Correct Answer is D

Explanation

Choice A rationale
Informing the charge nurse is an important step, but it is not the immediate action. The nurse should first assess the situation before escalating it.
Choice B rationale
Applying a dressing under the client’s nose might help manage the drainage, but it does not address the underlying issue. The drainage could be cerebrospinal fluid (CSF), which is a serious condition that needs immediate attention.
Choice C rationale
Checking the client’s temperature is a general assessment and does not directly relate to the symptom of clear nasal drainage.
Choice D rationale
Testing the drainage for glucose is the correct action. Clear nasal drainage after a basal skull fracture could be a sign of a cerebrospinal fluid (CSF) leak. CSF contains glucose, so testing the drainage for glucose can help confirm if it’s CSF34.

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The nurse is about to administer 1 liter (1000 mL) of 0.9% NS over 2 hours intravenously to a patient in shock. What rate should the nurse set on the infusion pump?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with partial-thickness and full-thickness burns on the head, neck, and chest. What is the primary risk to the client?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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The nurse is about to administer 1 liter (1000 mL) of 0.9% NS over 2 hours intravenously to a patient in shock.

What rate should the nurse set on the infusion pump?