A patient has orders to receive 1 L (1000 mL) of 5% dextrose and lactated Ringer’s solution to be infused over 8 hours. How many millilitres will be infused per hour?

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Question 1 of 9

A patient has orders to receive 1 L (1000 mL) of 5% dextrose and lactated Ringer’s solution to be infused over 8 hours. How many millilitres will be infused per hour?

Correct Answer: C

Rationale: The correct answer is C: 125 mL/h. To calculate the infusion rate per hour, we divide the total volume (1000 mL) by the total time in hours (8 hours). 1000 mL / 8 hours = 125 mL/h. This ensures a consistent and accurate infusion rate throughout the 8-hour period. Choice A (80 mL/h) is incorrect because it underestimates the infusion rate. Choice B (100 mL/h) is incorrect because it does not divide the total volume by the total time correctly. Choice D (150 mL/h) is incorrect because it overestimates the infusion rate.

Question 2 of 9

Following hypophysectomy, patients require extensive teaching regarding this major alteration in their lifestyle

Correct Answer: B

Rationale: The correct answer is B (Lifetime dependency on hormone replacement) because after hypophysectomy (removal of the pituitary gland), patients will no longer produce essential hormones like growth hormone, thyroid-stimulating hormone, etc. Therefore, they will require lifelong hormone replacement therapy to maintain normal bodily functions. A: Abnormal distribution of body hair is not directly related to hypophysectomy. C: While fluid intake may be important post-surgery, it is not the primary focus of teaching. D: There is typically no need for repeat surgical procedures after a hypophysectomy, as it is a one-time surgery to address specific issues. In summary, choice B is correct as it directly addresses the long-term implications of the surgery on hormone production and the need for replacement therapy, while the other choices are not directly relevant to the post-operative care of hypophysectomy patients.

Question 3 of 9

Mrs. Zeno asks the nurse why the disease has occurred. The nurse bases the reply on the knowledge that there is:

Correct Answer: C

Rationale: The correct answer is C because a decreased number of functioning acetylcholine receptor sites would result in the disease. Acetylcholine is a neurotransmitter that transmits signals between nerves and muscles. If there are fewer receptor sites for acetylcholine to bind to, this can lead to impaired nerve-muscle communication, causing the disease. Choice A is incorrect because a genetic defect in acetylcholine production would not directly affect the receptor sites. Choice B is incorrect because a reduced amount of acetylcholine would still be able to bind to the available receptor sites. Choice D is incorrect because inhibiting the enzyme Ache would not directly impact the receptor sites.

Question 4 of 9

A patient’s serum sodium is within normal range. The nurse estimates that serum osmolality should be:

Correct Answer: C

Rationale: The correct answer is C (280 to 295mOsm/kg) because serum osmolality is primarily determined by sodium, glucose, and blood urea nitrogen levels. Normal serum sodium range is 135-145 mEq/L, which corresponds to an osmolality range of 280-295 mOsm/kg. Choices A and B are incorrect as they do not align with normal serum sodium levels. Choice D is incorrect as it includes an excessively wide range that is not consistent with normal osmolality values.

Question 5 of 9

A client is being prepared for cardiac catheterization. The nurse performs an initial assessment and records the vital signs. Which of the following data collected can be classified as subjective data?

Correct Answer: B

Rationale: Subjective data refers to information provided by the client based on their feelings, perceptions, or beliefs. Nausea is a symptom that the client experiences and reports subjectively. The client feels nauseous, which is not something directly measurable like blood pressure, heart rate, or respiratory rate. Therefore, nausea is the correct choice for subjective data. Blood pressure, heart rate, and respiratory rate are all objective data that can be measured and observed. Blood pressure, heart rate, and respiratory rate are all objective data that can be measured and observed.

Question 6 of 9

Nurse Raymond is handling a group of student nurses and he is teaching them about fluids and electrolytes. He is correct when he says that a substance moves from an area of higher concentration, this is:

Correct Answer: C

Rationale: Correct Answer: C - Diffusion Rationale: Diffusion is the movement of a substance from an area of higher concentration to an area of lower concentration. This process occurs naturally to achieve equilibrium. In the context of fluids and electrolytes, this movement helps maintain balance within the body. Unlike osmosis, which involves the movement of water molecules across a semi-permeable membrane, diffusion applies to the movement of all types of substances. Filtration involves the movement of substances through a barrier under pressure, and active transport requires energy to move substances against a concentration gradient. Therefore, the correct answer is diffusion as it aligns with the principle of movement from high to low concentration for achieving equilibrium.

Question 7 of 9

Monthly examination (BSE) can help in early detection of breast CA. When do you perform BSE?

Correct Answer: A

Rationale: The correct answer is A: once a month after menstruation. Performing BSE at this time helps ensure consistent examination when breasts are less tender or swollen, making it easier to detect abnormalities. Performing it once a month ensures regular monitoring for any changes. Choices B, C, and D are incorrect because they do not provide the recommended frequency or timing for an effective BSE. BSE should be done monthly after menstruation to increase the chances of early detection of breast cancer.

Question 8 of 9

Which of the following is the humoral immune response?

Correct Answer: C

Rationale: The correct answer is C because in the humoral immune response, B cells are stimulated by T helper cells or macrophages to differentiate into plasma cells that produce antibodies or memory cells. This process involves the production of specific antibodies that target the foreign antigen. Choice A is incorrect because B cells do not phagocytize antigens; instead, they produce antibodies. Choice B is incorrect because T cells do not turn into plasma cells. It is the B cells that differentiate into plasma cells in the humoral immune response. Choice D is incorrect because T cells do not produce antibodies. T cells are involved in cell-mediated immunity, not the humoral immune response.

Question 9 of 9

Which of the ff factors makes it important for the nurse to provide special care to older clients with an immune system disorder?

Correct Answer: A

Rationale: The correct answer is A: Age-related changes. Older clients are more susceptible to immune system disorders due to age-related changes such as a weakened immune response, increased inflammation, and decreased production of immune cells. Providing special care is important to address these specific vulnerabilities. Incorrect choices: B: Use of multiple drugs (Polypharmacy) - While polypharmacy can impact the immune system, it is not the primary factor for providing special care to older clients with immune system disorders. C: Poor diet - While diet plays a role in overall health, it is not the main factor necessitating special care for older clients with immune system disorders. D: Reduced activity levels - Although physical activity is important for overall health, reduced activity levels are not the primary reason for providing special care to older clients with immune system disorders.

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