A nurse is reviewing a client's prescription for 1,000 ml of 5% dextrose in water IV to infuse over 8 hr. At 1400, the nurse observes that there is 500 ml of solution remaining in the client's current IV bag. At what time should the nurse administer the next bag of IV solution?
1700
1600
1500
1800
The Correct Answer is B
A. Incorrect. If the nurse administers the next bag at 1700, the current bag will run out before then, leaving the client without IV fluid for some time.
B. Correct. If the nurse administers the next bag at 1600, the current bag will have infused 750 ml by then, leaving 250 ml to infuse over the next hour. This will ensure a continuous and consistent infusion rate of 125 ml/hr.
C. Incorrect. If the nurse administers the next bag at 1500, the current bag will have infused only 625 ml by then, leaving 375 ml to infuse over the next hour. This will result in a faster infusion rate of 187.5 ml/hr, which may cause fluid overload or hyperglycemia in the client.
D. Incorrect. If the nurse administers the next bag at 1800, the current bag will run out before then, leaving the client without IV fluid for some time.
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Related Questions
Correct Answer is B
Explanation
A. Requesting a prescription for an indwelling urinary catheter should be considered a last resort. Catheters come with risks of infection and other complications, so they should only be used when other interventions have failed.
B. Taking the client to the bathroom every 2 hours is a proactive approach to managing urinary incontinence in older adults with dementia. This helps ensure that the client has regular opportunities to empty their bladder, reducing the likelihood of accidents.
C. Reminding the client to tell the nurse when he has to urinate may not be effective in clients with dementia, as they may have difficulty recognizing or communicating their need to urinate.
D. Using adult diapers should also be considered a last resort and should not be the primary intervention. While they can provide a temporary solution, they do not address the underlying issue and can contribute to skin problems if not changed frequently.
Correct Answer is A
Explanation
A. When administering a cleansing enema, it is important to hold the container of solution about 30 cm (12 in) above the anus. This provides enough gravitational force for the solution to flow gently into the rectum.
B. This action involves unnecessary movement of the container and is not a standard technique for administering a cleansing enema.
C. Holding the container level with the client's upper hip does not provide sufficient height for the gravitational force needed to administer the enema effectively.
D. Keeping the container at a level to maintain client comfort is not specific guidance for administering a cleansing enema. The height of the container above the anus is a critical factor in ensuring the enema flows properly.
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