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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 nurse is working in the cardiac unit when a Code Pink (infant abduction) is called. Which action by the nurse is the best response to the code?

Correct Answer: D

Rationale: Staying alert for a person of interest helps ensure hospital-wide vigilance during a Code Pink, regardless of the unit.

Question 3 of 5

Which assessment finding would the nurse expect in a client with long-term venous insufficiency with the presence of a venous ulcer?

Correct Answer: B

Rationale: Venous insufficiency causes stasis ulcers, typically over the medial malleolus, due to venous pooling and tissue breakdown.

Question 4 of 5

When drawing up a dosage of subcutaneous heparin, how much air should be drawn into the syringe after the correct dosage is obtained?

Correct Answer: C

Rationale: An air lock of 0.2-0.3 mL (
C) is used in subcutaneous heparin injections to ensure the full dose is delivered and to prevent leakage.

Question 5 of 5

A 6-month-old client is admitted with possible intussuception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis?

Correct Answer: C

Rationale: The usual diet is less directly related to diagnosing intussusception compared to symptoms like pain, vomiting, or abdominal changes.

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