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*The nurse is preparing a liquid medication for a 2-year-old. The
dose is 2.2 mL. What delivery device will the nurse select to
prepare the medication?*
A. 30 mL medication cup
B. 10 mL medication spoon
C. 3 mL needleless syringe
D. 5 mL medicine dropper Correct Answer C. 3 mL needleless
syringe
Rationale: Accuracy is most important when delivering small
amounts of medication to a child. The most accurate
dispensing device is the 3 mL needleless syringe that is
marked off in increments of tenths.
*The nurse is making an initial daily assessment at 0715 and
notes 550 mL of LR running at 75 mL an hour. At what time, in
,military time, will the nurse hang the next bag of IV fluid? _____*
Correct Answer Answer: 1435
Rationale:
550/75 = 7.3333
60 min × 0.33333 = 19.99 min = 20 min7 hr 20 min + 0715 =
1435
*In completing a client's preoperative routine, the nurse finds that
the operative permit is not signed. The client begins to ask more
questions about the surgical procedure. Which action should the
nurse take next?*
A. Witness the client's signature to the permit.
B. Answer the client's questions about the surgery.
C. Inform the surgeon the client has questions about the surgery.
D. Reassure the client that the surgeon will answer any questions
before the anesthesia is administered. Correct Answer C. Inform
the surgeon the client has questions about the surgery.
Rationale: It is the surgeon's responsibility to explain the
procedure to the client and obtain the client's signature on
the permit. Although the nurse can witness an operative
permit, the procedure must first be explained by the health
care provider or surgeon, including answering the client's
,questions. The client's questions should be addressed
before the permit is signed.
*Urinary catheterization is prescribed for a postoperative female
client who has been unable to void for 8 hours. The nurse inserts
the catheter, but no urine is seen in the tubing. Which action will
the nurse take next?*
A. Clamp the catheter and recheck it in 60 minutes.
B. Pull the catheter back 3 inches and redirect upward.
C. Leave the catheter in place and reattempt with another
catheter.
D. Notify the health care provider of a possible obstruction.
Correct Answer C. Leave the catheter in place and reattempt with
another catheter.
Rationale :It is likely that the first catheter is in the vagina,
rather than the bladder. Leaving the first catheter in place will
help locate the meatus when attempting the second
catheterization. The client should have at least 240 mL of
urine after 8 hours. Option A does not resolve the problem.
Option B will not change the location of the catheter unless it
is completely removed, in which case a new catheter must be
used. There is no evidence of a urinary tract obstruction if
the catheter could be easily inserted
, *The postoperative nurse is reviewing the use of an incentive
spirometer. Which instructions will the nurse include in the client's
teaching plan? (Select all that apply.)*
A. Sit in an upright position.
B. Cough deeply three times.
C. Hold breath for 5 seconds after inhaling on the spirometer.
D. Place mouth securely around the mouthpiece of the
spirometer.
E. Remove mouth from mouthpiece and exhale through the nose.
Correct Answer A. Sit in an upright position.
C. Hold breath for 5 seconds after inhaling on the spirometer
D. Place mouth securely around the mouthpiece of the
spirometer.
Rationale: After the spirometer is used the nurse can
encourage deep coughing. The client should exhale through
pursed lips. The remaining steps are correct.
*The nurse is providing care to a client who had major abdominal
surgery. Upon return from the recovery room, the client's vital
signs were at the pre-operative baseline. The client was sleepy,
but arousable, and the skin was warm and dry to the touch. At the
1 hour post admission assessment the nurse notes: heart rate
120 and thready, B/P 70/40 mm Hg, and the skin is cool and