Hesi Fundamentals 2 Practice Questions

The nurse observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first? a. observe the appearance of the skin under the ice pack b. instruct the client regarding the need for the covering c. reapply the covering after filling with fresh ice d. ask the client how long the ice was applied to the skin - Answer: a. observe the appearance of the skin under the ice pack Rationale: the first action taken by the nurse should be to assess the skin for any possible thermal injury (a). If no injury to the skin has occurred, the nurse can take the other actions b,c,d as needed. The nurse mixes 50 mg of Nipride in 250mL of D5W and plans to administer the solution at a rate of 5mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60gtt/mL how many drops per minute should the client receive? a. 31 gtt/min b. 62 gtt/min c. 93 gtt/min d. 124 gtt/min - Answer: d. 124 gtt/min Rationale: d is the correct calculation: 182/2.2 = 82.73 kg 5mcg x 82.73 = 413.65 mcg/min. 250/50,000mcg = 200 mcg/ml 413.65/200 = 2.07 mL 60 x 2.07 = 124.28 gtt/min The healthcare provider prescribes an IV infusion of 1,000mL Ringer's Lactate with 30 units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound infant by caesarean section. The tubing has been changed to a 20 gtt/mL administration set. The nurse plans to set the flow rate at how many gtt/min?