Questions 49

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ATI Nur 285 Med Surg Exam Questions

Extract:


Question 1 of 5

A client diagnosed with hyperosmolar hyperglycemia nonketonic syndrome (HHNS) was admitted yesterday with a blood glucose level of 700 mg/dL. The clients blood glucose level is now 250 mg/dL. Which intervention should the nurse implement?

Correct Answer: B

Rationale: When blood glucose drops significantly, insulin infusion rates are usually decreased to prevent hypoglycemia and a rapid fall in glucose levels.

Question 2 of 5

A nurse is preparing to administer Ringer's lactate 500 mL IV bolus to infuse over 3 hr. The drop factor of the manual IV tubing is 20 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer: 56

Rationale:
To calculate the flow rate for an IV bolus of Ringer's lactate to be infused over 3 hours, you would use the formula: (Volume in mL * Drop factor) / Time in minutes. For 500 mL of Ringer's lactate with a drop factor of 20 gtt/mL over 180 minutes (3 hours), the calculation would be (500 * 20) / 180, which equals 55.55. Rounding to the nearest whole number, the nurse should set the manual IV infusion to deliver 56 gtt/min.

Question 3 of 5

The client received ten (12) units of regular insulin at 08:00. At 11:30 the unlicensed assistant personnel (UAP) tells the nurse the client has a headache and is really acting funny. Which intervention should the registered nurse implement first?

Correct Answer: B

Rationale: Assessing the client is the first step to confirm hypoglycemia and determine the severity, allowing for appropriate intervention.

Question 4 of 5

A nurse is preparing to administer dextrose 5% in 0.45% sodium chloride 1L to infuse at 100 mL/hr. The nurse is using microtubing. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round to the nearest whole number.)

Correct Answer: 100

Rationale:
To calculate the manual IV infusion rate in drops per minute (gtt/min) when using microtubing, you can use the following formula: IV Drip Rate (gtt/min) = (Volume to be infused (mL) x Drop factor (gtt/mL)) / Time (min). Since microtubing typically has a drop factor of 60 gtt/mL, and the nurse is looking to infuse 1L (1000 mL) of solution at a rate of 100 mL/hr, the time to infuse 100 mL would be 60 minutes. Plugging these values into the formula gives: IV Drip Rate (gtt/min) = (100 mL x 60 gtt/mL) / 60 min, which simplifies to 100 gtt/min.

Question 5 of 5

A nurse is teaching a client who has diabetes mellitus about the manifestations of hypoglycemia. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer: A

Rationale: Shakiness is a classic symptom of hypoglycemia due to adrenaline release as the body responds to low glucose levels.

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