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A school-aged client is receiving vancomycin, 400 mg IV every 6 hours for a Methicillin-Resistant Staphylococcus Aureus (MRSA) infection. The medication is diluted in a 100 mL bag of 0.9% sodium chloride with instructions to infuse over one and a half hours. How many mL/hour should the nurse program the infusion pump? (Please enter the numeric value only. If rounding is required, round to the nearest whole number.

Answer and Explanation

The Correct Answer is ["67"]

Step 1: Convert the volume of fluid to be infused from mL to mL (since the rate is usually measured in mL/hr):

100 mL = 100 mL (No conversion needed as the volume is already in mL)

Step 2: Convert the time for infusion from hours to hours (since the rate is usually measured in mL/hr):

1.5 hours = 1.5 hours (No conversion needed as the time is already in hours)

Step 3: Calculate the rate (volume ÷ time):

Rate = Volume ÷ Time

Rate = 100 mL ÷ 1.5 hours

Rate = 66.67 mL/hr

So, the nurse should program the infusion pump to deliver at a rate of 67 mL/hr (rounded to the nearest whole number

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Choice A: Advise the UAP to resume positioning the client on schedule.

Reason: Turning the client from side to side is a critical nursing intervention to prevent complications such as pressure ulcers, pneumonia, and other issues related to immobility. Even though the client has a “Do Not Resuscitate” (DNR) order, it does not mean that comfort and preventive care measures should be stopped. The nurse should advise the UAP to continue with the scheduled positioning to ensure the client’s comfort and prevent further complications.

Choice B: Encourage the UAP to provide comfort care measures only.

Reason: While providing comfort care is essential, it does not mean that other necessary interventions, such as turning the client, should be neglected. Comfort care measures should include turning the client to prevent pressure ulcers and other complications. Therefore, this option is not the best choice as it may lead to neglecting important preventive care.

Choice C: Assume total care of the client to monitor neurologic function.

Reason: Assuming total care of the client is not practical and may not be necessary. The nurse should delegate tasks appropriately and ensure that the UAP is performing their duties correctly. Monitoring neurologic function is important, but it does not require the nurse to take over all aspects of the client’s care.

Choice D: Assign a practical nurse to assist the UAP in turning the client.

Reason: While assigning a practical nurse to assist the UAP might be helpful, it is not necessary if the UAP can resume the scheduled positioning on their own. The nurse should first advise the UAP to continue with the scheduled positioning before considering additional assistance.

A. A family member of a client with dementia who has been missing for five hours. B. A client with schizophrenia who wants to stop taking the medications. C. The parent of a child who was involved in a physical fight at school today. D. A client diagnosed with depression who is experiencing sexual dysfunction.

Correct Answer is A

Explanation

Choice A reason: The immediate safety of the client is at risk. A person with dementia who is missing poses a potential danger to themselves due to confusion and the inability to navigate safely in their environment.

Choice B reason: While medication adherence is important for a client with schizophrenia, it does not present an immediate life-threatening situation. The nurse can return this call after addressing more urgent safety concerns.

Choice C reason: Physical altercations at school are serious, but if the child is safe and not in immediate danger, this call can be returned following more urgent issues.

Choice D reason: Sexual dysfunction can significantly affect quality of life, but it is not an immediate safety concern. This call should be returned after more urgent calls have been addressed.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse working in the psychiatric clinic has phone messages from several clients. Which call should the nurse return first?

Correct Answer is A

Explanation

Patient Data Exhibits The nurse reviews the assessment findings along with the physician orders. Which immediate interventions would the nurse initiate? Select all that apply.

A client who is confined to a wheelchair as a result of a motorcycle accident is unable to feel pain or pressure from the waist down. Which finding provides the nurse with the earliest indication that the client is developing a pressure ulcer?

A nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?

Patient Data Exhibits Based on the results of the echocardiogram, the physician has decided to repair the ventricular septal defect via cardiac catheterization. What should the nurse’s focused assessment include before the cardiac catheterization? Select all that apply.

What conditions are most likely to respond to treatment with antihistamines? Select all that apply.

A client with bladder cancer had surgical placement of a ureter ileostomy (ileal conduit) yesterday. Which postoperative assessment finding should the nurse report to the healthcare provider immediately?