The nurse is preparing to administer 1600 mL of total parental nutrition (TPN) over 24 hours.

The nurse should set the IV pump to deliver how many mL/hr?

Answer and Explanation

The Correct Answer is ["66.7"]

Step 1 is (1600 mL ÷ 24 hours).

Answer is 66.7 mL/hr.

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Correct Answer is D

Explanation

Choice A rationale

Squeezing the nurse’s hand on verbal request suggests neurological improvement and does not warrant urgent intervention, indicating preserved motor response and cognition.

Choice B rationale

Following commands with repetition/prompting shows mild cognitive delay or reduced processing but does not represent deterioration or life-threatening concern needing immediate action.

Choice C rationale

Purposeful movement to sternal rub implies intact motor response to noxious stimuli. It does not indicate significant neurologic worsening requiring urgent intervention.

Choice D rationale

Extending extremities in response to painful stimuli, known as decerebrate posturing, is a severe neurologic deficit indicating brainstem dysfunction and requires immediate nursing intervention.

A. Ask the patient why they are behaving in this manner. B. Recommend an order for 1:1 observation status. C. Point out and identify the behavior as unacceptable. D. Have the patient return to his room when this occurs.

Correct Answer is C

Explanation

Choice A rationale

Asking the patient why they are behaving inappropriately does not address or stop the behavior. This approach may escalate the situation, leading to further discomfort for others.

Choice B rationale

Recommending 1: observation without addressing the behavior does not teach social boundaries. It is a passive solution that misses the opportunity for behavior correction.

Choice C rationale

Pointing out the behavior as unacceptable sets clear boundaries and educates the patient on appropriate social conduct. It creates an opportunity for the patient to reflect and adjust their behavior.

Choice D rationale

Having the patient return to their room may temporarily stop the behavior but does not educate the patient or reinforce appropriate boundaries for public settings.

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The nurse is preparing to administer 1600 mL of total parental nutrition (TPN) over 24 hours. The nurse should set the IV pump to deliver how many mL/hr?

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Correct Answer is D

Explanation

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The nurse is preparing to administer 1600 mL of total parental nutrition (TPN) over 24 hours.

The nurse should set the IV pump to deliver how many mL/hr?