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A client is receiving a secondary IV infusion of azithromycin 500 mg in 500 mL of normal saline (NS) to be infused over 2 hours. The IV administration set delivers 20 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

Answer and Explanation

The Correct Answer is ["83"]

Rationale:

Total volume to be infused = 500 mL.

Infusion time in minutes = 2 hours × 60 minutes/hour

= 120 minutes.

Drop factor of the IV administration set = 20 gtt/mL.

Calculate the flow rate in drops per minute (gtt/min).

Flow rate (gtt/min) = (Total volume (mL) × Drop factor (gtt/mL)) / Infusion time (min)

= (500 mL × 20 gtt/mL) / 120 min

= 10000 / 120 gtt/min

= 83.333... gtt/min.

Round the answer to the nearest whole number.

= 83 gtt/min

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Correct Answer is A

Explanation

A. Heart rate 100 beats/minute: A compensatory increase in heart rate (tachycardia) is expected in orthostatic hypotension. It helps maintain cerebral perfusion when blood pools in the lower extremities after standing quickly.

B. Blood pressure 125/65 mm Hg: This BP shows a slight systolic increase, which is not typical after orthostatic stress. A decrease in BP, not an increase, would be expected if symptoms like dizziness are present.

C. Heart rate 70 beats/minute: A decreased heart rate is not physiologically expected when someone experiences postural hypotension. Bradycardia would worsen cerebral perfusion and is inconsistent with dizziness.

D. Blood pressure 115/70 mm Hg: This change is too minor to explain dizziness. In orthostatic hypotension, we usually expect a drop of ≥20 mm Hg systolic or ≥10 mm Hg diastolic after position change.

A. Procure platelet products from the blood bank. B. Titrate oxygen to the prescribed parameters. C. Insert a urinary catheter for an uncomplicated client. D. Monitor an IV infusion rate on an established schedule.

Correct Answer is A

Explanation

A. Procure platelet products from the blood bank: UAPs may be delegated non-invasive tasks such as transporting lab specimens or retrieving blood products. This task does not require nursing judgment and is appropriate for delegation under routine supervision.

B. Titrate oxygen to the prescribed parameters: Titrating oxygen requires assessment and clinical judgment, as adjustments depend on vital signs and client condition. This is within the RN or LPN scope, not the UAP’s, due to the potential for rapid status changes.

C. Insert a urinary catheter for an uncomplicated client: Insertion of catheters is an invasive procedure that requires sterile technique and knowledge of anatomy. This task must be performed by a licensed nurse, not a UAP, even in uncomplicated cases.

D. Monitor an IV infusion rate on an established schedule: Although observation is within the UAP role, monitoring IV infusions involves understanding flow rates, recognizing signs of infiltration or complications, and making clinical decisions, all of which exceed UAP scope.

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Naxlex Comprehensive Predictor Exams

A client's most recent vital signs include heart rate 80 beats/minute and blood pressure 119/70 mm Hg. When the client reports dizziness after rising quickly, which finding should the nurse expect on reassessment?

Correct Answer is A

Explanation

After receiving a change of shift report for clients on a medical surgical unit, which task should the nurse assign to an unlicensed assistive personnel (UAP)?

Correct Answer is A

Explanation

Exhibits The nurse calls the healthcare provider (HCP) to notify them that the digoxin level is above therapeutic range. Place the nurse statements in Situation, Background, Assessment, Recommendation (SBAR) format. Each column must have only one response selected.

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The parent of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The parent reports no evidence of watery stools. Which nursing intervention should the nurse implement?

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The nurse is reviewing the plan of care for a newly admitted client who is intoxicated on admission. Which findings should the nurse include as indicators to begin implementing the detoxification medication protocol?