A nurse is preparing to start an IV infusion of lactated Ringer’s for a client who sustained a burn injury.

The client is prescribed 5,200 mL of fluid over the first 24 hr. How many mL/hr should the nurse set the pump to infuse for the first 8 hr? (Round the answer to the nearest whole number.

Use a leading zero if it applies. Do not use a trailing zero.)

Answer and Explanation

The Correct Answer is ["325"]

Step 1 is to determine the total volume of fluid to be infused in the first 8 hours. According to the Parkland formula for fluid resuscitation, half of the prescribed volume is administered in the first 8 hours. Thus:

Total fluid for the first 8 hours = 5,200 mL ÷ 2 = 2,600 mL.

Step 2 is to calculate the infusion rate in mL/hr for the first 8 hours. Divide the total volume for the first 8 hours by the total time in hours:

Infusion rate = 2,600 mL ÷ 8 hr = 325 mL/hr.

Final calculated answer: 325 mL/hr.

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Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale

Fever usually accompanies myocardial infarction. This statement is incorrect. While fever can occur with myocardial infarction, it is not a common or primary symptom. Acetaminophen is not prescribed for this reason.

Choice B rationale

Acetaminophen does not interfere with platelet action as acetylsalicylic acid (aspirin) does. This statement is correct but not the reason for prescribing acetaminophen before nitrates. Acetaminophen is chosen for its analgesic properties without affecting platelet function.

Choice C rationale

Headache is a common side effect of nitrates. This statement is correct. Nitrates can cause vasodilation, leading to headaches. Acetaminophen is prescribed to manage this common side effect.

Choice D rationale

Acetaminophen potentiates the therapeutic effect of nitrates. This statement is incorrect. Acetaminophen does not enhance the therapeutic effects of nitrates; it is used to manage side effects like headaches.

A. Provide diversionary activities for the client. B. Assist the client with toileting at frequent intervals. C. Involve the family in the client’s care. D. Explain to the client that he will be restrained if he does not stop pulling on his NG tube. E. Use an electronic bed alarm device.

Correct Answer is ["A","B","C","E"]

Explanation

Choice A rationale

Providing diversionary activities for the client can help distract them and reduce the likelihood of them pulling on their NG tube. Diversionary activities can include engaging the client in conversation, providing them with puzzles or games, or allowing them to watch television or listen to music. These activities can help occupy the client’s time and attention, reducing the need for restraints.

Choice B rationale

Assisting the client with toileting at frequent intervals can address any discomfort or need that may be causing the client to pull on their NG tube. Ensuring that the client is comfortable and their needs are met can reduce agitation and the likelihood of them pulling on the tube.

Choice C rationale

Involving the family in the client’s care can provide additional support and reassurance to the client. Family members can help calm the client and provide a familiar presence, which can reduce anxiety and the need for restraints.

Choice E rationale

Using an electronic bed alarm device can alert the nursing staff if the client attempts to get out of bed or pull on their NG tube. This allows for timely intervention without the need for physical restraints.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is caring for a client who is cognitively impaired and repeatedly pulls on his NG tube. Which of the following actions should the nurse take before requesting a prescription for restraints? (Select all that apply.)

Correct Answer is ["A","B","C","E"]

Explanation

A nurse is working with a licensed practical nurse (LPN) to care for a client who is receiving a continuous IV infusion. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site?

A client arrived via ambulance to the emergency department with a chief complaint of gastrointestinal bleeding for 2 hours. What will the triage nurse do first?

A nurse is assessing a client who has rheumatoid arthritis. Which of the following findings should the nurse expect?

A nurse is caring for a client who has a full arm cast and reports a pain level of 8 on a scale of 0 to 10, which is unrelieved by pain medication. Which of the following actions should the nurse plan to take first?

The emergency service team brings a homeless client found lying in an alley to the emergency department. An assessment is performed, and the client is suspected of having frostbite of the hands. Which finding would the nurse expect to note in this condition?

A nurse is caring for a client. Exhibits Select the 5 findings that can cause delayed wound healing.

A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation. Which of the following findings should the nurse plan to monitor for and report to the provider immediately?

A nurse is caring for an older adult client who had a femoral head fracture 24 hr ago and is in skin traction. The client reports shortness of breath and dyspnea. The nurse should suspect that the client has developed which of the following complications?