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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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Correct Answer is C

Explanation

The correct answer is: c. Inspiratory and expiratory bilateral crackles.

Choice A: Average urine output of 28 mL/hour

Reason: The normal urine output for an adult is typically 0.5 mL/kg/hr, which translates to about 30-50 mL/hr for most adults. An average urine output of 28 mL/hour is slightly below this range, indicating possible inadequate fluid resuscitation. However, it is not immediately life-threatening and does not warrant the most urgent intervention compared to other options.

Choice B: Vesicular bibasilar breath sounds

Reason: Vesicular breath sounds are normal lung sounds heard over most of the lung fields. They are soft and low-pitched, indicating that the airways are clear. Therefore, vesicular bibasilar breath sounds do not indicate any immediate respiratory distress or fluid overload and do not require urgent intervention.

Choice C: Inspiratory and expiratory bilateral crackles

Reason: Crackles, also known as rales, are abnormal lung sounds that indicate the presence of fluid in the alveoli. Bilateral crackles heard during both inspiration and expiration suggest significant pulmonary edema or acute respiratory distress syndrome (ARDS), which can be life-threatening and requires immediate intervention.

Choice D: Central venous pressure of 12 mm Hg

Reason: The normal range for central venous pressure (CVP) is 2-8 mm Hg. A CVP of 12 mm Hg is elevated, indicating possible fluid overload or heart failure. While this is concerning and requires monitoring, it is not as immediately critical as bilateral crackles, which directly affect oxygenation and respiratory function.

A. Obtain satisfaction with appearance. B. Achieve steady weight loss. C. Institute an exercise plan. D. Regulate food portions.

Correct Answer is D

Explanation

Choice A reason: While obtaining satisfaction with appearance is an important long-term goal, it is not the first step in treatment. Addressing the behavior itself is crucial before tackling self-image issues.

Choice B reason: Achieving steady weight loss is a goal that will likely result from regulating food portions and other treatment interventions. It is not the initial focus when establishing treatment goals.

Choice C reason: Instituting an exercise plan is part of a comprehensive treatment plan but is secondary to establishing control over eating behaviors.

Choice D reason: Regulating food portions is essential for reducing the frequency and volume of binge eating episodes, which is the immediate concern in binge eating disorder management.

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A client with 50% full-thickness burns has received fluid resuscitation for the past 24 hours. Which assessment warrants immediate intervention by the nurse?

Correct Answer is C

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A nurse is caring for a client with binge eating disorder. Which goal should the nurse establish first with the client?

Correct Answer is D

Explanation

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