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 B

Explanation

A. While antibiotics may be necessary if a UTI is confirmed, requesting a prescription would not be the immediate nursing action. The nurse must first assess the situation thoroughly and obtain necessary diagnostic information before medications can be prescribed.
B. This option is the most appropriate immediate action. Obtaining a full set of vital signs helps assess
the client’s overall condition, including the degree of fever and any signs of systemic infection. Collecting

a urine specimen will facilitate further evaluation, such as a urinalysis and culture, to confirm a UTI and identify the appropriate antibiotic treatment.
C. While increasing fluid intake can help with urinary tract health and dilute the urine, it is not an immediate priority in this situation. The client may need more urgent assessment and possible medical intervention rather than just dietary changes.
D. Although protective isolation may be warranted given the client’s immunocompromised state due to chemotherapy and radiation, it is not the immediate priority based on the current symptoms. The focus should first be on assessing and addressing the potential UTI.

A. Impulsive behavior and hostility toward family B. Hemiparesis of the client's left arm and apraxia C. Homonymous hemianopia on the left side and diplopia D. Paralysis of the right side of the body and ataxia

Correct Answer is D

Explanation

A. These are behavioral changes that may occur after a stroke, but they are not directly related to motor loss.
B. Hemiparesis is weakness on one side of the body, but in this case, the client is experiencing motor loss on the right side. Apraxia is the inability to perform purposeful movements, which can also occur after a stroke, but it is not a direct manifestation of motor loss.
C. Homonymous hemianopia is the loss of vision in half of the visual field on the same side as the stroke. Diplopia is double vision. While these are both common symptoms of stroke, they are not related to motor loss.
D. A left-sided stroke typically results in motor loss on the right side of the body. This is because the left side of the brain controls the right side of the body. Additionally, ataxia, which is a lack of coordination, is a common symptom of stroke.

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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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Correct Answer is B

Explanation

The nurse is assessing a client experiencing motor loss as the result of a left-sided stroke. Which of the following clinical manifestations related to motor loss would the nurse document?

Correct Answer is D

Explanation

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