A nurse is preparing to administer 400 mL of 0.9% sodium chloride IV over 8 hours.
The drop factor of the manual IV tubing is 60 gtt/mL.
The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number.
Use a leading zero if it applies. Do not use a trailing zero.).
The Correct Answer is ["50"]
To calculate the flow rate in gtt/min, you need to divide the total volume of the IV fluid (400 mL) by the total infusion time in minutes (8 hours x 60 minutes/hour = 480 minutes) and then multiply by the drop factor of the manual IV tubing (60 gtt/mL).
This gives you a flow rate of (400 mL / 480 minutes) x 60 gtt/mL = 50 gtt/min.
The other choices are not answers because they are not provided in the question.
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Correct Answer is A
Explanation
The nurse should inform the charge nurse about her suspicion.
The charge nurse is responsible for managing the unit and can take appropriate action to investigate the matter and ensure that proper procedures are followed.
Choice B is incorrect because reporting the incident to the hospital security department is not the first step that should be taken.
The charge nurse should be informed first and can then decide if further action, such as involving the security department, is necessary.
Choice C is incorrect because it is not appropriate for the nurse to ask assistant personnel (AP) to observe the other nurse’s actions.
This could create a hostile work environment and may not be an effective way to address the issue.
Choice D is incorrect because approaching the other nurse directly to discuss the suspicion may not be the best course of action.
It could create tension and conflict between the two nurses and may not lead to a resolution of the issue.
Instead, informing the charge nurse allows for proper procedures to be followed in addressing the matter.
Correct Answer is A
Explanation
The nurse should include in the teaching that the client should use a soft-bristled toothbrush.
Heparin is an anticoagulant that decreases the clotting ability of the blood 1.
Using a soft-bristled toothbrush can help prevent bleeding of the gums while brushing teeth.
Choice B is incorrect because heparin should not be injected deep into the thigh muscle.
Instead, it should be given subcutaneously (under the skin) 2.
Choice C is incorrect because black and tarry stools are not an expected side effect of heparin.
Choice D is incorrect because easy bruising does not indicate that the medication is effective.
Instead, easy bruising may be a side effect of heparin and should be reported to the healthcare provider 1.
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