Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is reviewing a client's prescription for 1,000 ml of 5% dextrose in water IV to infuse over 8 hr. At 1400, the nurse observes that there is 500 ml of solution remaining in the client's current IV bag. At what time should the nurse administer the next bag of IV solution?
A. 1700
Incorrect. If the nurse administers the next bag at 1700, the current bag will run out before then, leaving the client without IV fluid for some time.
B. 1600
This choice is incorrect. Check Choice D rationale
C. 1500
Incorrect. If the nurse administers the next bag at 1500, the current bag will have infused only 625 ml by then, leaving 375 ml to infuse over the next hour. This will result in a faster infusion rate of 187.5 ml/hr, which may cause fluid overload or hyperglycemia in the client.
D. 1800
The total volume to infuse is 1,000 ml over 8 hours, which calculates to a rate of 125 ml/hour (1,000 ml ÷ 8 hr). By 1400, the client has already received 500 ml (since there is 500 ml remaining in the IV bag). The infusion has been running for 4 hours (from 1000 to 1400), which means the nurse has infused 500 ml (125 ml/hour × 4 hours). Since there are 500 ml remaining in the bag, it will take another 4 hours to complete the infusion (500 ml ÷ 125 ml/hour). Therefore, if the nurse administers the next bag immediately after the current one runs out, it will be at 1800 (1400 + 4 hours). However, the timing of administering the next bag depends on when the current bag will run out. Since there is still 500 ml remaining, it will take 4 more hours until the IV solution runs out, which is at 1800.
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Full Explanation
The total volume to infuse is 1,000 ml over 8 hours, which calculates to a rate of 125 ml/hour (1,000 ml ÷ 8 hr).
- By 1400, the client has already received 500 ml (since there is 500 ml remaining in the IV bag).
- The infusion has been running for 4 hours (from 1000 to 1400), which means the nurse has infused 500 ml (125 ml/hour × 4 hours).
- Since there are 500 ml remaining in the bag, it will take another 4 hours to complete the infusion (500 ml ÷ 125 ml/hour).
- Therefore, if the nurse administers the next bag immediately after the current one runs out, it will be at 1800 (1400 + 4 hours).
- However, the timing of administering the next bag depends on when the current bag will run out. Since there is still 500 ml remaining, it will take 4 more hours until the IV solution runs out, which is at 1800.
Similar Questions
A nurse is caring for several clients who are at various developmental stages. The nurse should explain that, according to Erikson, acceptance of death is a primary task of which of the following stages of psychosocial development?
A. Autonomy vs. shame and doubt
Autonomy vs. shame and doubt focuses on developing a sense of independence and autonomy in early childhood (around 1-3 years old). It does not directly involve acceptance of death.
B. Identity vs. role diffusion
Identity vs. role diffusion pertains to adolescence (around 12-18 years old) and involves the development of a sense of self and one's role in society. It does not specifically address the acceptance of death.
C. Integrity vs. despair
Integrity vs. despair is the stage that occurs in late adulthood (65 years and older), where individuals reflect on their lives. Acceptance of death is a significant aspect of achieving a sense of integrity during this stage.
D. Generativity vs. stagnation
Generativity vs. stagnation occurs in adulthood (around 40-65 years old) and involves concerns about contributing to the next generation and leaving a legacy. While mortality may be a consideration, it is not the primary task of this stage.
Full Explanation
A. Autonomy vs. shame and doubt focuses on developing a sense of independence and autonomy in early childhood (around 1-3 years old). It does not directly involve acceptance of death.
B. Identity vs. role diffusion pertains to adolescence (around 12-18 years old) and involves the development of a sense of self and one's role in society. It does not specifically address the acceptance of death.
C. Integrity vs. despair is the stage that occurs in late adulthood (65 years and older), where individuals reflect on their lives. Acceptance of death is a significant aspect of achieving a sense of integrity during this stage.
D. Generativity vs. stagnation occurs in adulthood (around 40-65 years old) and involves concerns about contributing to the next generation and leaving a legacy. While mortality may be a consideration, it is not the primary task of this stage.
A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered?
A. Troponin
Troponin is a marker for cardiac muscle damage. It is not directly related to anorexia and malnutrition.
B. Creatine kinase
Creatine kinase is also a marker for muscle damage, particularly in conditions like heart attacks or muscular disorders. It is not directly related to anorexia and malnutrition.
C. Total bilirubin
Total bilirubin is related to liver function. While severe malnutrition can affect liver function, it's not the primary marker for malnutrition.
D. Albumin
Albumin is a protein synthesized by the liver and is an important indicator of nutritional status. In cases of malnutrition, especially protein-calorie malnutrition, serum albumin levels tend to decrease. This is due to the body's decreased ability to synthesize proteins when there is a lack of adequate nutrition.
Full Explanation
A. Troponin is a marker for cardiac muscle damage. It is not directly related to anorexia and malnutrition.
B. Creatine kinase is also a marker for muscle damage, particularly in conditions like heart attacks or muscular disorders. It is not directly related to anorexia and malnutrition.
C. Total bilirubin is related to liver function. While severe malnutrition can affect liver function, it's not the primary marker for malnutrition.
D. Albumin is a protein synthesized by the liver and is an important indicator of nutritional status. In cases of malnutrition, especially protein-calorie malnutrition, serum albumin levels tend to decrease. This is due to the body's decreased ability to synthesize proteins when there is a lack of adequate nutrition.
A nurse is caring for a group of clients on a medical-surgical unit. Which of the following situations requires that the nurse wear gloves? (Select all that apply.)
A. Providing oral care
Providing oral care involves contact with mucous membranes and saliva, which may contain blood or other potentially infectious materials. Therefore, the nurse should wear gloves to protect themselves and the client from cross-contamination.
B. Emptying urine from an indwelling urine collection bag
Emptying urine from an indwelling urine collection bag involves contact with urine, which may contain blood or other potentially infectious materials. Therefore, the nurse should wear gloves to protect themselves and the client from cross-contamination.
C. Placing oral medication tablets into a client's hand
Placing oral medication tablets into a client's hand does not involve contact with blood or other potentially infectious materials. Therefore, the nurse does not need to weargloves for this task.
D. Delivering a food tray to a client who has AIDS
Delivering a food tray to a client who has AIDS does not involve contact with blood or other potentially infectious materials. Therefore, the nurse does not need to wear gloves for this task. However, the nurse should follow standard precautions and wash their hands before and after contact with any client.
E. Changing an ostomy pouch
Changing an ostomy pouch involves contact with feces, which may contain blood or other potentially infectious materials. Therefore, the nurse should wear gloves to protect themselves and the client from cross-contamination.
Full Explanation
A. Providing oral care involves contact with mucous membranes and saliva, which may contain blood or other potentially infectious materials. Therefore, the nurse should wear gloves to protect themselves and the client from cross-contamination.
B. Emptying urine from an indwelling urine collection bag involves contact with urine, which may contain blood or other potentially infectious materials. Therefore, the nurse should wear gloves to protect themselves and the client from cross-contamination.
C. Placing oral medication tablets into a client's hand does not involve contact with blood or other potentially infectious materials. Therefore, the nurse does not need to wear
gloves for this task.
D. Delivering a food tray to a client who has AIDS does not involve contact with blood or other potentially infectious materials. Therefore, the nurse does not need to wear gloves for this task. However, the nurse should follow standard precautions and wash their hands before and after contact with any client.
E. Changing an ostomy pouch involves contact with feces, which may contain blood or other potentially infectious materials. Therefore, the nurse should wear gloves to protect themselves and the client from cross-contamination.