A client returns to the acute care unit following surgery with 0.9% normal saline infusing at 45 drops/minute through tubing with a drop factor of 60 drops per ml. The postoperative prescriptions include 0.9% normal saline at 75 ml/hour to alternate with Lactated Ringer's solution at 75 ml/hour. An intravenous infusion pump is not available. What action should the nurse implement?

Change the normal saline to a keep open rate until an infusion pump is available.

Increase the rate of the present normal saline infusion to 75 drops per minute.

Leave the normal saline at the current rate until an infusion pump is available.

Switch the saline to Lactated Ringer's solution infusing at 75 drops per minute.

Answer and Explanation

The Correct Answer is C

Choice A: Changing the normal saline to a keep-open rate (KVO) is not appropriate in this situation, as the client has specific fluid orders that need to be followed, and a KVO rate would not provide the prescribed maintenance fluids.

Choice B: Increasing the rate of the present normal saline infusion to 75 drops per minute would not meet the prescription for 0.9% normal saline at 75 ml/hour.

Adjusting the rate this way would require an infusion pump.

Choice C: Leaving the normal saline at the current rate until an infusion pump is available is the most appropriate action. It ensures that the client continues to receive fluids at the ordered rate until the necessary equipment is in place.

Choice D: Switching the saline to Lactated Ringer's solution infusing at 75 drops per minute would not meet the prescribed rate for the normal saline solution. The nurse should follow the specific orders provided.

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Correct Answer is C

Explanation

Choice A: Sitting quietly in her mother's lap may be a sign of shyness or caution in a healthcare setting, but it is not necessarily a typical behavior for a 4-year-old child.

Choice B: Drawing a picture of oneself with facial features is a more advanced skill and may be seen in older preschool-aged children. It is not a typical behavior for a 4- year-old.

Choice C: Talking to an imaginary friend is a normal and developmentally appropriate behavior for a 4-year-old child. Imaginary friends can provide comfort and companionship during times of stress or change.

Choice D: Ignoring other children in the play area may be a sign of shyness or introverted behavior but is not necessarily indicative of normal behavior for a 4-year-old. Social interaction with peers can vary widely among children.

A. Maintain protein intake and increase intake of fruits and vegetables. B. Decrease protein intake and eat more whole grains and vegetables. C. Increase protein intake with the additional intake of dairy products. D. Maintain protein intake but substitute fish and nuts for meat and eggs.

Correct Answer is D

Explanation

Choice A: Maintaining protein intake and increasing intake of fruits and vegetables is generally a balanced and healthy approach to nutrition.

Choice B: Decreasing protein intake and eating more whole grains and vegetables may not be necessary unless there are specific dietary restrictions or medical indications.

Choice C: Increasing protein intake with additional dairy products may not be needed and depends on individual dietary preferences and nutritional goals.

Choice D: Maintaining protein intake but substituting fish and nuts for meat and eggs can be a balanced and healthy dietary choice. Fish and nuts can provide protein and healthy fats while reducing saturated fat intake from red meat and eggs.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 4-year-old girl returns to the pediatrician's office for a postoperative visit following hospitalization for minor surgery. When observing the child in the waiting area, which behavior should-the nurse consider normal for this age child

Correct Answer is C

Explanation

A 30-year-old male client tells the nurse that about half of his diet comes from eating meat and eggs. What instruction should the nurse provide?

Correct Answer is D

Explanation

The nurse is assessing the reflexes of a 35-year-old client who came to the clinic for an annual physical exam. When the nurse strikes the patellar tendon, there is no response. What action should the nurse take next?

The nurse is performing a nutritional assessment on a client who is professional dancer. Which issue reported by the client should alert the nurse to perform further assessment?

A client who has migraine headaches wants to decrease the intake of foods high in tyramine to see if that will reduce the occurrence of headaches. Which food should the nurse recommend that the client eliminate?

The nurse is admitting an older client with possible malnutrition. Which parameters are most indicative of the client's nutritional status?

The nurse is helping develop a meal plan based on nutritional guidelines for a 73-year-old client being discharge to home with the client's 65- year-old spouse. Which statement best indicates an understanding of the nutritional guidelines when planning meals by the two spouses?

The nurse is planning a nutrition class for vegans. Which food should the nurse encourage to be combined with other foods to enhance the nutritional intake in the vegan diet?

Which pathology of autonomic cardiac regulation is mediated by sympathetic innervation?

The nurse is caring for a client diagnosed with type 1 diabetes mellitus who uses both short-acting and long-acting insulin adjusted doses throughout the day. Which nutrient is essential for the client to count for each meal and snacks?