The nurse receives report at 0700 on a client who has 500 mL of IV fluid left in the bag. The IV is running at 125 mL per hour. At what time should the nurse expect to change the bag (military time)?

1500

1200

1100

0200

Answer and Explanation

The Correct Answer is C

A.   1500 is 8 hours after 0700, which is too long for the remaining fluid to last.
B.   1200 is 5 hours after 0700, which means there would still be fluid left in the bag at this time.
C.   1100 is exactly 4 hours after 0700, which aligns with our calculation of when the remaining 500 mL will be finished.
D.   0200 is 19 hours after 0700, which is far too late for the IV fluid to last.

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Correct Answer is C

Explanation

A. While the nursing student may assist with feeding, the nurse should always assess the client's swallowing ability and provide direct supervision to ensure the client's safety.
B. Placing food on the affected side of the mouth can increase the risk of aspiration. The food should be placed on the unaffected side of the mouth.
C. Distractions can impair the client's ability to focus on swallowing and increase the risk of aspiration. A quiet environment can help the client concentrate on eating.
D. The head of the bed should be elevated to at least 30 degrees during and after feeding to reduce the risk of aspiration.

A. Avoid sexual activity for twelve hours B. Teach to self-catheterize every 4 hours C. Urinate in a sitting position post infusion D. Increase fluid intake for 8 hours prior to infusion

Correct Answer is C

Explanation

A. After intravesical therapy, there may be recommendations to avoid sexual activity for a certain period (often 24 hours) to prevent exposure to the medication by a partner. However, the specifics can vary based on the medication used. Twelve hours might not be sufficient depending on the protocol.
B. Self-catheterization is not routinely required unless there is a specific reason (e.g., urinary retention or difficulty voiding). This statement is not relevant to the therapy itself.
C. Urinating in a sitting position can help ensure more complete emptying of the bladder and can be safer, particularly for women. It also may minimize contact with any residual medication in the bladder, which can be a consideration post-infusion.
D. Patients are usually advised to avoid excessive fluid intake immediately before the infusion to prevent bladder distention during the treatment.

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Blood Cell	Normal Ranges
Red blood cells (mature, circulating)	Male 4.51-6.01 million/mm3 Female: 4.01-5.51 million/mm3
Hemoglobin	Adult (15-64 yr) Male 14-17.3 g/dL Female 11.7-15.5 g/dL
Hematocrit	42% -52% in males 36% -48% in females
Reticulocytes	0.5% -2.5% of total RBC count
White blood cells (total)	4.5-11.1 103/mm3
Neutrophils	59% Bands 3% Segs-56%
Eosinophils	2.7%
Basophils	0.5%
Lymphocytes	34%
Monocytes	4%
Platelets	150,000-450,000/mm3

The nurse receives report at 0700 on a client who has 500 mL of IV fluid left in the bag. The IV is running at 125 mL per hour. At what time should the nurse expect to change the bag (military time)?

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