As a nurse, you are reviewing the orders and planning initial steps for caring for the same patient.
Which interventions should you perform?

Check capillary refill on bilateral upper extremities.

Administer morphine 2 mg IV as ordered.

Perform range of motion exercises.

Administer ondansetron 4 mg IV as ordered.

Answer and Explanation

Correct Answer : A,B,D

Choice A rationale

Checking capillary refill on bilateral upper extremities can help assess peripheral circulation and identify any potential vascular injuries.

Choice B rationale

Administering morphine 2 mg IV as ordered would help manage the patient’s pain.

Choice C rationale

Performing range of motion exercises may not be appropriate immediately after the fall and before the extent of the patient’s injuries are fully assessed.

Choice D rationale

Administering ondansetron 4 mg IV as ordered can help manage any nausea or vomiting that the patient may experience, which can be a side effect of the morphine or a result of the fall itself. TemazepamTemazepam Explore

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Correct Answer is ["21"]

Explanation

Step 1 is: Convert 12 hours into minutes. 12 hours × 60 minutes/hour = 720 minutes.

Step 2 is: Calculate the infusion rate. (1000 mL ÷ 720 minutes) × 15 gtt/mL = 20.83 gtt/min. Therefore, the infusion rate should be approximately 21 gtt/min when rounded to the nearest whole number.

A. Polycythemia. B. Temperature.

Correct Answer is A

Explanation

Choice A rationale

The child’s symptoms, including clear and equal lung sounds, a murmur upon auscultation, and clubbing of the fingers, suggest a condition affecting the heart and lungs. Polycythemia, a condition characterized by an increased number of red blood cells, could explain these symptoms. The nurse should monitor the child’s hematocrit and hemoglobin levels, as these can be elevated in polycythemia. The nurse should also monitor the child’s oxygen saturation, as hypoxia can occur in polycythemia3.

Choice B rationale

While temperature is an important vital sign to monitor in any patient, it does not directly address the child’s symptoms or the likely underlying condition. Therefore, it is not the most relevant choice in this scenario3. Diabetic ketoacidosisDiabetic ketoacidosis Explore

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As a nurse, you are reviewing the orders and planning initial steps for caring for the same patient.Which interventions should you perform?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient has been prescribed 1 L of Lactated Ringer’s IV to be infused over a 12-hour period. The IV administration set delivers 15 gtt/mL. What should be the infusion rate in gtt/min? (Provide a numerical value only. If rounding is required, round to the nearest whole number.)

Correct Answer is ["21"]

Explanation

Correct Answer is A

Explanation

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As a nurse, you are reviewing the orders and planning initial steps for caring for the same patient.
Which interventions should you perform?