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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: A thready pulse is one that is weak and can be easily obliterated by light pressure.
Choice B: A missing pulse is one that cannot be felt at all.
Choice C: "Pulse skips beats" is a different phenomenon and not an accurate description of the pulse disappearing with light pressure. It is irregular and may indicate a cardiac arrhythmia.
Choice D: Documenting "light pressure applied to pulse" does not convey the specific finding that the pulse disappears with pressure, which is more clinically relevant. It is not a finding, but a method of assessing the pulse.
Correct Answer is D
Explanation
Choice A: A mechanical soft diet may still require some degree of chewing, which may be difficult for a client with no teeth. A pureed diet would be a more appropriate choice.
Choice B: A soft low-residue diet may include soft foods that require chewing, which could be challenging for a client with no teeth.
Choice C: A full liquid diet consists of liquids and foods that are in liquid form at room temperature, which may not provide adequate nutrition for the client.
Choice D: A pureed diet involves blending foods to a smooth consistency, making them suitable for clients with no teeth or difficulty chewing. It would be the most appropriate choice.
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