An adult has and IV line in the right forearm infusing D5 ½ NS with 20 mEq of potassium at 75 ml/h. which statement would be a correct report from the RN?

Correct Answer: C

Rationale: Correct Answer: C Rationale: 1. Potassium is typically administered on a secondary line to prevent rapid infusion and potential adverse effects. 2. The primary line carries the D5 ½ NS solution without potassium, while the secondary line delivers the potassium. 3. Reporting that "potassium is on the secondary line" accurately describes the setup for this IV infusion. Summary: A: Incorrect - Incorrectly states that the potassium bag is piggybacked into the dextrose. B: Incorrect - Closing the clamp below the D5 ½ NS bag is unnecessary and does not address the potassium infusion. D: Incorrect - Fails to address the specific issue of the potassium infusion being on a secondary line.

Correct Answer: C

Rationale: The correct answer is C: Performing a physical examination. This method allows the nurse to gather comprehensive data about the patient's health status, including vital signs, physical appearance, and potential health issues. It provides valuable information for developing an individualized care plan. Reviewing literature (A) is important but not for establishing a patient's database. Checking orders (B) and ordering medications (D) are part of the treatment process and do not directly contribute to establishing the initial patient database.

Correct Answer: C

Rationale: The correct answer is C: Diagnostic reasoning. The nurse is using assessment data to analyze, interpret, and make a judgement about the patient's condition. This process involves critical thinking skills to develop a nursing diagnosis. Choice A (Assigning clinical cues) is incorrect because it refers to identifying specific signs and symptoms. Choice B (Defining characteristics) is incorrect as it pertains to the features of a diagnosed condition. Choice D (Diagnostic labeling) is incorrect because it focuses on naming a specific nursing diagnosis. Diagnostic reasoning encompasses the entire process of analyzing data, making connections, and formulating a nursing diagnosis based on critical thinking.

Correct Answer: B

Rationale: Step 1: High cholesterol levels contribute to the buildup of plaque in arteries, leading to atherosclerosis and increasing the risk of coronary artery disease. Step 2: Atherosclerosis can result in a blockage of blood flow to the heart, causing a myocardial infarction (MI). Step 3: Age is a risk factor for CAD but not directly linked to MI development. Step 4: Medication usage may impact risk factors but is not a direct cause of MI. Step 5: Gender can influence risk but is not the primary factor in MI development.

Correct Answer: C

Rationale: The correct answer is C: Diagnostic reasoning. Diagnostic reasoning involves using assessment data and critical thinking skills to develop a nursing diagnosis. This process includes analyzing and interpreting data to make clinical judgments about the patient's health status. A: Assigning clinical cues is incorrect because this refers to identifying and documenting specific observations or findings during the assessment process, not the process of developing a nursing diagnosis. B: Defining characteristics is incorrect because this refers to the specific symptoms or manifestations used to support a nursing diagnosis, not the overall process of diagnostic reasoning. D: Diagnostic labeling is incorrect because this refers to assigning a formal name to the nursing diagnosis, not the process of critically analyzing assessment data to develop it.

Correct Answer: E

Rationale: The correct answer is missing from the choices provided. However, for a client with an immune system disorder, essential nursing actions include: E: Educate the client on the importance of maintaining a healthy lifestyle, avoiding exposure to infections, and adhering to prescribed medications. This is crucial for managing the immune system disorder effectively. Incorrect choices: A: Following agency guidelines is important but doesn't specifically address the client's immune system disorder. B: Reviewing drug references may be necessary but is not a priority in managing the immune system disorder. C: Advising the client on modifying the home environment is not directly related to managing the immune system disorder. D: Monitoring the client for depression is important but not specific to addressing the immune system disorder.

Correct Answer: B

Rationale: To calculate the mL needed for the injection, divide the prescribed dose by the concentration of the medication. In this case, 30 mg ÷ 50 mg/mL = 0.6 mL. However, since the nurse should round up to ensure the full dose is administered, the correct answer is 0.7 mL. Choice A is incorrect as it is rounded down. Choice C is incorrect as it is the exact division without rounding up. Choice D is incorrect as it is rounded up too much.

Correct Answer: D

Rationale: The correct answer is D, suggesting the use of glasses or contact lenses. This is because as older clients experience lens changes associated with aging, they may develop presbyopia or other vision issues that can be corrected with corrective lenses. Glasses or contact lenses can help improve their vision and quality of life. A, offering teaching aids with large-sized letters, may be helpful for clients with visual impairments but may not directly address the specific lens changes associated with aging. B, suggesting reduced visual activity, is not beneficial as it may further limit the client's engagement in daily activities and social interactions. C, suggesting the use of eye drops for comfort, may provide temporary relief for dry eyes but does not address the underlying lens changes affecting vision.

Correct Answer: B

Rationale: The correct answer is B because rifampin can cause discoloration of bodily fluids, including tears. If clients wear contact lenses, they need to be informed that the lenses may become colored due to this medication. This is important for the client's awareness and to prevent any potential harm to their eyes. A: Taking medication with meals is not necessary for rifampin administration. C: Avoiding wearing glasses is not relevant to rifampin treatment. D: Avoiding tuna, aged cheese, and red wine is not specifically related to rifampin use.