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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A: Taking a prescribed analgesic an hour prior to breastfeeding can help alleviate the client's intense cramping while breastfeeding. This approach can provide effective pain relief.

Choice B: Changing the infant's position during the next feeding may or may not address the underlying cause of the client's intense cramping. Pain relief through medication is a more direct intervention.

Choice C: Drinking water before breastfeeding is important for hydration but may not directly address the cramping issue.

Choice D: Voiding and emptying the bladder before each feeding is a routine practice but is not specifically aimed at relieving cramping during breastfeeding.

A. Inform the client that oatmeal contains gluten. B. Encourage the client to choose decaffeinated coffee. C. Commend the client for selecting fat free milk. D. Advise the client that too much fruit can irritate the colon.

Correct Answer is A

Explanation

Choice A: Oatmeal is often considered a source of gluten, which should be avoided by individuals with celiac disease. The nurse should inform the client that oatmeal may not be suitable for a gluten-free diet.

Choice B: Encouraging the client to choose decaffeinated coffee is a minor consideration and is not the most important action related to celiac disease.

Choice C: Commending the client for selecting fat-free milk is unrelated to the issue of gluten in the oatmeal and is not the most important action.

Choice D: Advising the client about the potential irritant effects of too much fruit on the colon is not directly related to the issue of gluten in the oatmeal and is not the most important action.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is multiparous on the postpartum unit reports intense cramping while breastfeeding. What instruction should the nurse provide to this client?

Correct Answer is A

Explanation

A client with celiac disease selects a bowl of oatmeal with fresh fruit and skim milk, grapefruit juice, and coffee from the breakfast menu. Which action is most important for the nurse to implement?

Correct Answer is A

Explanation

While assessing placement of a nasogastric tube (NGT), the nurse aspirates cloudy green fluid into a syringe. Which intervention should the nurse Implement?

The nurse-manager of a pediatric unit needs to assign a room for a 6-month-old diagnosed with respiratory syncytial virus (RSV). Which room assignment is best for the nurse-manager to make?

A client who was recently diagnosed with atrial fibrillation is receiving warfarin. To see the drug's effectiveness, which laboratory finding should the practical nurse (PN) review?

An adult client with a diagnosis of bipolar disorder arrives in an elated state on admission to the psychiatric unit. What is the best room assignment the nurse can make for this client?

An adult male client with chronic kidney disease (CKD) is receiving aluminum hydroxide (Amphojel). He tells the nurse that since he does not have indigestion there is no need for him to take the antacid with his meals. Which response is best for the nurse to provide?

The unlicensed assistive personnel (UAP) who is caring for a postoperative client reports to the charge nurse that the client is not using the incentive spirometer effectively. What action should the charge nurse implement?

The practical nurse (PN) observes an infant searching for a fallen toy. According to Piaget, which additional finding should the PN correlate with this developmental stage?

The nurse is caring for an older client with that is exhibiting signs of confusion. Which intervention should the nurse implement?