The nurse is preparing to administer 1 liter (1000 mL) of 0.9% NS over 2 hours intravenously to a patient experiencing shock. At what rate will the nurse set the infusion pump? Enter the number only.

Answer and Explanation

The Correct Answer is ["8.3"]

Step 1: Total volume = 1000 mL (which is 1 liter)

Step 2: Total time = 2 hours. But since the infusion pump rate is typically set in mL per minute, we need to convert this to minutes. There are 60 minutes in an hour, so 2 hours is 2 × 60 = 120 minutes.

Step 3: Now we can calculate the rate. The rate is the total volume divided by the total time. So, the rate = 1000 mL ÷ 120 minutes.

Calculating the above gives us the rate at which the nurse will set the infusion pump. Let's calculate it:

Step 4: Rate = 1000 mL ÷ 120 minutes = 8.33 mL/minute.

So, the nurse will set the infusion pump at a rate of approximately 8.33 mL per minute. If rounding is required, this can be rounded to 8.3 mL per minute.

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Correct Answer is D

Explanation

Choice A reason: Instructing the client to expect tingling in their extremities is not a standard post-lumbar puncture care instruction. Tingling may be a sign of nerve irritation or damage, which is not an expected outcome and should be reported if it occurs.

Choice B reason: Measuring blood glucose every 2 hours is not related to post-lumbar puncture care unless the client has a specific condition that requires such monitoring. Post-lumbar puncture care focuses on preventing complications such as headaches and monitoring for signs of infection or bleeding.

Choice C reason: Limiting the client's fluid intake is not advised following a lumbar puncture. In fact, increasing fluid intake can help prevent the occurrence of post-lumbar puncture headaches, which are a common complication. Adequate hydration helps replenish cerebrospinal fluid and reduce headache severity.

Choice D reason: Instructing the client to lie flat is the correct action. After a lumbar puncture, it is recommended that the client lies flat for several hours to prevent the leakage of cerebrospinal fluid from the puncture site, which can lead to a spinal headache. Lying flat helps maintain normal cerebrospinal fluid pressure and reduces the risk of headache.

A. Check the client's blood pressure every 8 hours. B. Monitor for hypokalemia as a manifestation of acute rejection. C. Assess urine output hourly. D. Administer opioids orally.

Correct Answer is C

Explanation

Choice A reason: Checking the client's blood pressure every 8 hours is important, but it is not as critical as monitoring urine output in the immediate postoperative period. Blood pressure should be monitored regularly, but changes in urine output can provide more immediate information about the new kidney's function.

Choice B reason: Monitoring for hypokalemia is important, as it can be a sign of acute rejection; however, hyperkalemia is more commonly associated with acute rejection due to the kidney's inability to excrete potassium. Therefore, while electrolyte monitoring is crucial, the focus is typically on hyperkalemia rather than hypokalemia.

Choice C reason: Assessing urine output hourly is essential for a client who has undergone a kidney transplant. Urine output is a direct indicator of the new kidney's function, and any significant decrease could indicate a complication such as acute rejection or obstruction.

Choice D reason: Administering opioids orally for pain management is part of postoperative care, but it is not the priority over monitoring urine output and kidney function.

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The nurse is preparing to administer 1 liter (1000 mL) of 0.9% NS over 2 hours intravenously to a patient experiencing shock. At what rate will the nurse set the infusion pump? Enter the number only.

Nursing Test Bank

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Correct Answer is C

Explanation

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