The nurse recognizes that the appropriate rationale for using an IV infusion pump for a client is to:

eliminate the hourly assessment of the IV site.

prevent accidental delivery of large amounts of fluids.

control the drip rate based on the position of the client.

administer IV fluids at a rapid rate.

Answer and Explanation

The Correct Answer is B

B. One of the primary functions of an IV infusion pump is to precisely control the rate and volume of fluid delivery, thereby reducing the risk of accidental administration of large amounts of fluids. The pump allows for accurate programming of infusion rates and volume limits, enhancing safety and preventing fluid overload or other complications.
A. Using an IV infusion pump does not eliminate the need for assessing the IV site regularly. Regardless of the infusion method, it is essential to monitor the IV site frequently for signs of complications such as infiltration, phlebitis, or dislodgement. Therefore, this option is not the appropriate rationale for using an IV infusion pump.

C. IV infusion pumps are programmable devices that allow for precise control of the drip rate independent of the client's position. They ensure a consistent and controlled flow rate regardless of changes in the client's position, providing reliable delivery of fluids or medications.
D. While IV infusion pumps can deliver fluids at various rates, including rapid infusion rates when necessary, their primary purpose is not to administer fluids at a rapid rate. Rather, they are designed to deliver fluids or medications at controlled and programmed rates tailored to the client's needs, ensuring safety and accuracy.

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Correct Answer is ["A","C"]

Explanation

A. Enteral nutrition can be used when a client is unable to consume adequate nutrition orally or when oral intake is contraindicated. It can be used as a supplement to oral intake or as the sole source of nutrition, depending on the client's condition and nutritional needs.
C. Enteral nutrition can be administered either intermittently, where feedings are given at specific times throughout the day, or continuously, where a steady infusion is delivered over an extended period, typically 16 to 24 hours. The method of administration depends on the client's tolerance, nutritional needs, and clinical condition.
B. Enteral nutrition typically consists of liquid formulas specifically designed to provide complete and balanced nutrition. These formulas come in various formulations, including standard polymeric formulas, high-protein formulas, elemental formulas, and disease-specific formulas. They are not thinned pureed food, which is typically used for clients with dysphagia or swallowing difficulties who are receiving oral feeding.
D. While some enteral nutrition formulas may contain dairy-based ingredients, such as milk protein or lactose, not all enteral formulas are milk-based. There are various types of enteral formulas available, including those that are lactose-free, soy-based, or elemental (containing predigested nutrients), to accommodate different dietary preferences and tolerances.
E. Enteral nutrition is administered directly into the gastrointestinal tract, typically through a feeding tube that is inserted into the stomach or small intestine. It is not given intravenously (through a vein), which would be parenteral nutrition.

A. Have the client return demonstrate self-measurement of blood pressure B. Ask the client what he needs to know about the diagnosis C. Encourage the client to discuss his feelings about his health status D. Provide brochures on current exercise and nutrition guidelines

Correct Answer is C

Explanation

C. Encourage the client to discuss his feelings about his health status: This option directly targets the affective domain by facilitating the expression and exploration of the client's emotions, attitudes, and beliefs related to their health status. Discussing feelings can help the client process emotions such as fear, anxiety, or frustration, and can promote emotional coping, self-awareness, and acceptance, all of which are important aspects of affective learning.
A. This option primarily involves the psychomotor domain, as it focuses on the client's ability to perform a physical skill (self-measurement of blood pressure). While this activity may indirectly influence the affective domain by building the client's confidence and sense of empowerment in managing their health, its primary focus is on the acquisition of motor skills.
B. This option engages the cognitive domain by encouraging the client to identify and express their informational needs about their diagnosis. While this approach can help address cognitive aspects of learning, such as knowledge acquisition and understanding, it may not directly target the affective domain unless the client's emotional responses and concerns are explicitly addressed.
D. Providing educational materials on exercise and nutrition guidelines can contribute to cognitive learning by imparting information about health behaviors but it may not directly address the affective domain unless the content specifically addresses emotional or motivational aspects of behavior change. However, if the brochures include content that inspires or motivates the client to adopt healthy lifestyle changes by appealing to their values, beliefs, or emotions, then it could indirectly influence the affective domain.

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The nurse recognizes that the appropriate rationale for using an IV infusion pump for a client is to:

Nursing Test Bank

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Explanation

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Correct Answer is C

Explanation

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