A client is ordered to receive a bolus of 200 mL of NSS in 25 minutes. At what rate should the nurse set the IV pump?

Answer and Explanation

The Correct Answer is ["480"]

To calculate the infusion rate, you need to determine the total volume to be infused and the time over which it will be infused.

Total volume to be infused = 200 mL

Time for infusion = 25 minutes

Infusion rate = Total volume / Time Infusion rate = 200 mL / 25 minutes = 8 mL/min

To convert this to mL/hour (since infusion pumps are typically set in mL/hour): Infusion rate = 8 mL/min × 60 minutes/hour = 480 mL/hour

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Correct Answer is D

Explanation

A. "I will have some pain that is similar to a toothache.": This statement shows an understanding that discomfort can occur after a bone marrow aspiration, which is a common experience.

B. "I understand that this is a sterile procedure.": This demonstrates awareness of the importance of sterility during the procedure to prevent infection, which is accurate.

C. "The nurse will check the puncture site at least every 4 hours after the procedure.": This indicates an understanding of the need for monitoring the puncture site for complications such as bleeding or infection, which is an appropriate expectation.

D. "The nurse will give me one 650 mg tablet of Aspirin for pain when the procedure is over.": This statement indicates a need for additional teaching because aspirin can increase the risk of bleeding, particularly after a procedure involving puncturing the skin. Generally, acetaminophen (Tylenol) would be recommended for pain relief instead of aspirin.

A. Place a pad under the buttocks B. Check the rectal area for soiling frequently C. Wash the buttocks with strong soap and water D. Place the call bell in each reach

Correct Answer is B

Explanation

A) Place a pad under the buttocks: While this can help absorb moisture, it does not directly prevent skin breakdown from fecal contact. Pads may provide some protection but are not a comprehensive solution.

B) Check the rectal area for soiling frequently: This is the best intervention to help prevent skin breakdown. Regular checks allow for prompt cleaning and care of the area, minimizing the risk of irritation and pressure injuries associated with stool incontinence.

C) Wash the buttocks with strong soap and water: Using strong soap may irritate the skin and is not recommended. Gentle cleansing with mild soap is preferred, but this action alone does not address the need for frequent monitoring and prompt care.

D) Place the call bell in reach: While this encourages the client to call for assistance when needed, it does not actively prevent skin breakdown from stool incontinence. Prompt attention to soiling is more effective in protecting the skin.

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A client is ordered to receive a bolus of 200 mL of NSS in 25 minutes. At what rate should the nurse set the IV pump?

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Naxlex Comprehensive Predictor Exams

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