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Questions 149

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Question 1 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 2 of 5

A client with heart failure has a left ventricular ejection fraction of 38%. When educating the client about managing the condition, which of the following advice should the nurse include? Select all that apply.

Correct Answer: A,B,D

Rationale: Rest periods (
A), avoiding strenuous activities (
B), and stopping smoking (
D) manage heart failure. All exercise (
C) is not stopped; moderate activity is encouraged. Alcohol should be minimal, not 2-3 drinks (E).

Question 3 of 5

According to Maslow's hierarchy of needs, order the following needs from most basic to most advanced (bottom of the pyramid to the top):

Order the Items

Source Container

safety and security
esteem
physiological
love and belonging
self-actualization

Correct Answer: C,A,D,B,E

Rationale: Maslow’s hierarchy: physiological (most basic), safety and security, love and belonging, esteem, self-actualization (most advanced).

Question 4 of 5

A pneumonectomy is performed on a client with lung cancer. Which of the following would probably be omitted from the client's plan of care?

Correct Answer: A

Rationale: After a pneumonectomy, the affected lung is removed, and the pleural space fills with fluid naturally, so closed chest drainage is typically not used, unlike in other lung surgeries.

Question 5 of 5

A client with a tracheostomy is exhibiting difficulty breathing, and respirations are increasingly noisy. Secretions are very thick. Which of the following initial interventions is most indicated?

Correct Answer: A

Rationale: Thick secretions causing noisy respirations and breathing difficulty indicate the need for increased humidification to thin secretions and suctioning to clear the tracheostomy tube (
A). Notifying the physician (
B) or encouraging coughing (
C) is secondary, and irrigation (
D) is not typically the initial step.

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