Extract:

Question 1 of 5

A client is receiving IV fluids at 100 ml per hour. The nurse is told in report at 1200 that there are 500 ml left in the bag. At what time should the nurse expect to hang a new bag? Report the time in military time.

Correct Answer: 1700

Rationale: Calculate the remaining volume of fluid: Remaining volume =
Total volume - Volume infused. Remaining volume = 1000 mL - 500 mL = 500 mL. Calculate the remaining infusion time: Remaining infusion time = Remaining volume / Infusion rate. Remaining infusion time = 500 mL / 100 mL/hr = 5 hours. Determine the time the infusion will be complete: Current time: 1200 (12:00 PM). Remaining infusion time: 5 hours. Time of completion: 1200 (12:00 PM) + 5 hours = 1700.
Therefore, the nurse should expect to hang a new bag at 1700.

Question 2 of 5

A physical therapist is helping nursing students to understand the correct use of ambulatory devices. The students realize that the correct statement(s) made is/are: (SELECT ALL THAT APPLY)

A. A cane is held on a client's weaker side for support.B. Cane tips should have rubber caps and be in good repair to prevent slippage.C. When using a walker, the client should first move the walker ahead approximately six inches, and then step into it.D. Clients need to have at least partial strength in their hands, wrists, elbows, arms and shoulders to correctly use a standard walker.E. When using crutches, the client's body weight should rest on the axillae.

Correct Answer: B,C,D

Rationale: The cane should be held on the stronger side to support the weaker side. Rubber caps prevent the cane from slipping, enhancing safety. Moving the walker first provides stability before the client steps into it. Adequate upper body strength is necessary to use a standard walker effectively. Body weight should be supported on the hands, not the axillae, to avoid nerve damage.

Question 3 of 5

A client is diagnosed with asthma. The therapeutic regimen using metered dose inhalers includes albuterol 2 puffs and beclomethasone 2 puffs. The nursing plan of care must include teaching regarding:

A. Effective coughing after medication administration.B. Rinsing the mouth after beclomethasone administration.C. Using beclomethasone as needed when breathing normally.D. Taking the beclomethasone first, followed by the albuterol.

Correct Answer: B

Rationale: Rinsing after beclomethasone (
B) prevents oral thrush. Coughing (
A) isn't needed, beclomethasone is regular (
C), and albuterol goes first (
D).

Question 4 of 5

A nurse is caring for a client who is hospitalized with active pulmonary tuberculosis and is started on ethambutol therapy. The nurse should understand that which of the following should be monitored?

A. Skin colorB. Visual acuityC. Cardiac rhythmD. Urine output

Correct Answer: B

Rationale: Ethambutol can cause optic neuropathy; visual acuity (
B) must be monitored. Skin color (
A), cardiac rhythm (
C), and urine output (
D) are not primary concerns.

Question 5 of 5

The client has had a total hip replacement. The nurse teaches the client about safe positions for the client for sexual intercourse. These include: (SELECT ALL THAT APPLY)

A. side-lying on unaffected side with pillows between the legs.B. side-lying on affected side.C. on hands and knees.D. Client on top.E. Supine

Correct Answer: A,E

Rationale: Side-lying on the unaffected side with pillows between the legs can maintain proper hip alignment and prevent dislocation, which is critical after a hip replacement. Side-lying on the affected side could cause risk of hip dislocation and is not recommended. The 'on hands and knees' position should be avoided as it may place strain on the hip joint and cause dislocation. 'Client on top' is typically not recommended as it can lead to excessive flexion or rotation of the hip, which could lead to dislocation. Lying supine can also be a safe position if the client avoids bending the hip past 90 degrees, which could cause dislocation.