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Questions 157

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Question 1 of 5

The nurse is administering 250 mL of packed red blood cells with 50 mL of preservative. The client has no jugular vein distention and has clear breath sounds. After the first 15 minutes, at what rate should the nurse set the IV infusion pump?

Correct Answer: 75

Rationale:
Total volume: 250 mL + 50 mL = 300 mL. Infuse over 4 hours (standard): 300 mL / 4 hr = 75 mL/hr.

Question 2 of 5

When interviewing the client of Hindu heritage, which information should the nurse obtain to plan culturally sensitive care?

Correct Answer: B

Rationale: Ayurveda, common in Hindu culture, may influence health practices (e.g., herbs, diet), guiding culturally sensitive care. Advance directives, interpreters, and allergies are general, not Hindu-specific.

Question 3 of 5

Which assessment data indicate the treatment for the client diagnosed with bacterial meningitis is effective?

Correct Answer: D

Rationale: Neck flexibility without pain indicates reduced meningeal inflammation, a sign of effective meningitis treatment.

Question 4 of 5

The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a medical floor. Which nursing task could be delegated to the UAP?

Correct Answer: C

Rationale: Routine vital sign collection is within UAP scope, unlike post-medication BP, HCP notification, or lab discussions.

Question 5 of 5

The nurse assessing an elderly client diagnosed with chronic obstructive pulmonary disease notes purple, round, nontender areas on the client's back. Which question should the nurse ask the client?

Correct Answer: A

Rationale: Purple, round marks suggest cupping, a traditional therapy for respiratory issues, common in some cultures. Bruising, abuse, or client causation are less likely without evidence.

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