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Questions 149

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Question 1 of 5

The charge nurse overhears the patient care assistant speaking harshly to the client with dementia. The charge nurse should:

Correct Answer: B

Rationale: Exploring the interaction addresses the behavior appropriately.

Question 2 of 5

The nurse has an order to give 1,000 mL of 0.9% NS with 20 meQ of potassium chloride over 8 hours. The IV set has a drop factor of 15. How many gtts/min should the client receive?

Correct Answer: 31

Rationale: Rate = 1,000 mL ÷ 8 hr = 125 mL/hr. Drops/min = (125 mL/hr × 15 gtts/mL) ÷ 60 min = 31.25 gtts/min, rounded to 31 gtts/min.

Question 3 of 5

The nurse is assessing an ECG strip of a 42-year-old client and finds a regular rate greater than 100, a normal QRS complex, a normal P wave in front of each QRS, a PR interval between 0.12 and 0.20 seconds, and a P: QRS ratio of 1:1. What is the nurse's interpretation of this rhythm?

Correct Answer: B

Rationale: A regular rate >100 with normal P waves, QRS complexes, and PR interval indicates sinus tachycardia, a common response to stress, fever, or hypoxia.

Question 4 of 5

All of the following are risk factors for sudden infant death syndrome (SIDS) EXCEPT

Correct Answer: B

Rationale: Placing an infant on their back to sleep reduces SIDS risk. Low birth weight, young maternal age, and maternal smoking are known risk factors.

Question 5 of 5

A client in cardiac arrest is given 40 units of vasopressin (Pitressin) IV push. The nurse knows the desired action of this medication in a cardiac arrest is to

Correct Answer: A

Rationale: Vasopressin, used in cardiac arrest, is a vasopressor that raises blood pressure by vasoconstriction, improving perfusion during CPR.

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