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Questions 149

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Question 1 of 5

The nurse assesses a new order for a blood transfusion. The order is to transfuse 1 unit of packed red blood cells (contains 250 mL) in a 2-hour period. What will be the hourly rate of infusion?

Correct Answer: C

Rationale:
To calculate the hourly rate: 250 mL ÷ 2 hours = 125 mL/hr, ensuring the transfusion is completed within the prescribed time.

Question 2 of 5

The client is newly diagnosed with juvenile onset diabetes. Which of the following nursing diagnoses is a priority?

Correct Answer: C

Rationale: Knowledge deficit is a priority, as education on managing juvenile diabetes is critical for long-term health and compliance.

Question 3 of 5

The nurse is serving on the performance improvement committee, which has agreed to some changes in procedures on the basis of evidence-based research. If the committee wants to convince staff members to comply with the changes, which of the following actions should the committee carry out first?

Correct Answer: A

Rationale: Gaining key staff support (
A) builds buy-in and facilitates change adoption. Consequences (
B), rewards (
C), or written expectations (
D) follow.

Question 4 of 5

A client with pancreatitis has been transferred to the intensive care unit. The nurse assesses a pulmonary arterial wedge pressure (PAWP) of 14 mmHg. Based on this finding, the nurse would want to further assess for:

Correct Answer: B

Rationale: A PAWP of 14 mmHg is slightly elevated, suggesting possible fluid overload, which could lead to pulmonary edema, indicated by rales on chest auscultation.

Question 5 of 5

The charge nurse considers both patient-related and staff-related factors when making daily assignments. All of the following are patient-related factors EXCEPT

Correct Answer: D

Rationale: Nurse-to-client ratio is a staff-related factor, affecting workload distribution. Ventilation, medications, and isolation are patient-specific needs.

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