Detailed hAnswer hKey
NR h226 hMay h2020 hExam h1
hWilliams
1. A hnurse his hcaring hfor ha hclient hwho hrefuses htreatment hand hasks hto hbe hdischarged hfrom hthe
hhospital hagainst hmedical hadvice. hThe hnurse hnotifies hthe hclient's hprovider, hwho htells hthe hnurse hto
hrestrain hthe hclient, hif hnecessary, hto hkeep hher hfrom hleaving hthe hhospital. hThe hnurse hunderstands
hthat hrestraining hthis hclient hwould hbe hconsidered hwhich htype hof hcivil haction hby hthe hnurse?
A. Invasion hof hprivacy
Rationale: hInvasion hof hprivacy his hdefined has hfailure hto hrespect ha hclient’s hright hto hmanage htheir hown
haffairs.
This hsituation hdoes hnot hdescribe hinvasion hof hprivacy.
B. Assault
Rationale: hAssault his hdefined has hthreatening hto hinflict hinjury hon ha hclient hor han hattempt hto
hdo hharm. hThis hsituation hdoes hnot hdescribe hassault.
C. Battery
Rationale: hBattery his hdefined has hintentionally htouching ha hclient hwithout hher hconsent. hThis
hsituation hdoes hnot hdescribe hbattery.
D. False himprisonment
Rationale: hFalse himprisonment his hdetaining ha hclient hagainst hher hwill hto hseek hfreedom. hThe
hclient hhas hthe hright hto hrefuse htreatment hagainst hmedical hadvice hand hleave hthe
hhospital.
2. An hassistive hpersonnel h(AP) hreports ha hclient’s hvital hsigns has htympanic htemperature h37.1° hC
h(98.8° hF), hpulse h92/min, hrespiratory hrate h18/min, hand hBP h98/58 hmm hHg. hWhich hof hthe hfollowing
hvital hsigns hshould hthe hnurse hre-measure?
A. BP
Rationale: hA hnurse hwho his hsupervising han hAP's hwork his haccountable hfor hthe hwork hthat hthe hAP
hcompletes.
Therefore, hthe hnurse hshould hverify hanything hthat hseems hunusual. hThe hBP hthe hAP
hreported his hlow; htherefore, hthe hnurse hshould hverify hthat hthis hresult his haccurate
hbefore htaking hany hother hactions.
B. Respiratory hrate
Rationale: hThis hrespiratory hrate his hwithin hthe hexpected hreference hrange. hUnless hit hdeviates
hmarkedly hfrom hthe hclient’s husual hreadings, hthe hnurse hneed hnot htake hany haction
hat hthis htime.
C. Pulse hrate
Rationale: hThis hpulse hrate his hwithin hthe hexpected hreference hrange. hUnless hit hdeviates
hmarkedly hfrom hthe hclient’s husual hreadings, hthe hnurse hneed hnot htake hany haction
hat hthis htime.
D. Temperature
Rationale: hThis htemperature hreading his hwithin hthe hexpected hreference hrange. hUnless hit
hdeviates hmarkedly hfrom hthe hclient’s husual hreadings, hthe hnurse hneed hnot htake
hany haction hat hthis htime.
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, Detailed hAnswer hKey
NR h226 hMay h2020 hExam h1
hWilliams
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, Detailed hAnswer hKey
NR h226 hMay h2020 hExam h1
hWilliams
3. A hnurse his hpreparing hto hinfuse ha h250-mL hunit hof hpacked hRBCs hover h2 hhr. hThe hdrop hfactor hof
hthe hmanual hIV htubing his h15 hgtts/mL. hThe hnurse hshould hadjust hthe hflow hrate hto hdeliver hhow
hmany hdrops hper hminute? h(Round hthe hanswer hto hthe hnearest hwhole hnumber. hUse ha hleading hzero
hif hit happlies. hDo hnot huse ha htrailing hzero.)
31 h gtt/min
Correct hRationale: hFollow hthese hsteps hto hcalculate hthe hinfusion hrate:
Step h1: hWhat his hthe hunit hof hmeasurement hthe hnurse hshould
hcalculate? hgtt/min hStep h2: hWhat his hthe hvolume hthe hnurse hshould
hinfuse? h250 hmL
Step h3: hWhat his hthe htotal hinfusion htime? h2 hhr
Step h4: hShould hthe hnurse hconvert hthe hunits hof hmeasurement? hYes h(min
hdoes hnot hequal hhr) h1 hhr/60 hmin h= h2 hhr/X hmin
X h= h120 hmin
Step h5: hSet hup han hequation hand hsolve hfor
hX. hVolume h(mL)/Time h(hr) hx hdrop hfactor
h(gtt/mL) h= hX h250 hmL/120 hmin hx h15
hgtt/mL h= hX hgtt/min
31.25 h= hX
Step h6: hRound hif hnecessary. h31.25 h= h31
Step h7: hReassess hto hdetermine hwhether hthe hamount hto hadminister hmakes
hsense. hIf hthe hprescription hreads hone h250-mL hunit hof hpacked hcells hto hinfuse
hIV hover h2 hhr, hit hmakes hsense hto hadminister h31 hgtt/min. hThe hnurse hshould
hadjust h hthe hmanual hIV hinfusion hto hdeliver hthe hpacked hRBCs hat h31 hgtt/min.
InCorrect hRationale: h Follow hthese hsteps hto hcalculate hthe hinfusion hrate:
Step h1: hWhat his hthe hunit hof hmeasurement hthe hnurse hshould
hcalculate? hgtt/min hStep h2: hWhat his hthe hvolume hthe hnurse hshould
hinfuse? h250 hmL
Step h3: hWhat his hthe htotal hinfusion htime? h2 hhr
Step h4: hShould hthe hnurse hconvert hthe hunits hof hmeasurement? hYes h(min
hdoes hnot hequal hhr)
1 hhr/60 hmin h= h2
hhr/X hmin hX h= h120
hmin
Step h5: hSet hup han hequation hand hsolve hfor
hX. hVolume h(mL)/Time h(hr) hx hdrop hfactor
h(gtt/mL) h= hX h250 hmL/120 hmin hx h15
hgtt/mL h= hX hgtt/min
31.25 h= hX
Step h6: hRound hif hnecessary. h31.25 h= h31
Step h7: hReassess hto hdetermine hwhether hthe hamount hto hadminister hmakes
hsense. hIf hthe hprescription hreads hone h250-mL hunit hof hpacked hcells hto
hinfuse hIV hover h2 hhr, hit hmakes hsense hto hadminister h31 hgtt/min. hThe hnurse
hshould hadjust h hthe hmanual hIV hinfusion hto hdeliver hthe hpacked hRBCs hat h31
hgtt/min.
4. A hcharge hnurse his hplanning ha hroom hassignment hfor ha hclient hwho hhas ha hproductive hcough, ha
hquestionable hchest hx-ray, hand ha hpositive hMantoux htest. hRoom h208 his ha hprivate, hnegative-pressure
hairflow hroom; hroom h212 his ha hsemi-private, hpositive-pressure hairflow hroom; h214 his ha hnegative-
pressure, hsemi-private hroom; hand hroom h216 his ha hprivate,
positive-pressure hairflow hroom. hTo hwhich hof hthe hfollowing hrooms hshould hthe hnurse hassign hthe hclient?
A. h 208
Rationale: hA hclient hwho hhas hor hmight hhave htuberculosis hrequires hairborne hprecautions. hThat
hmeans ha hprivate hroom hwith hnegative-pressure hairflow. hRoom h208 his hthe honly hone
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, Detailed hAnswer hKey
NR h226 hMay h2020 hExam h1
hWilliams
hof hthese hoptions hthat hfits hthese hrequirements.
B. h 212
Rationale:
Created Page h
hon:05/14/2020 4
NR h226 hMay h2020 hExam h1
hWilliams
1. A hnurse his hcaring hfor ha hclient hwho hrefuses htreatment hand hasks hto hbe hdischarged hfrom hthe
hhospital hagainst hmedical hadvice. hThe hnurse hnotifies hthe hclient's hprovider, hwho htells hthe hnurse hto
hrestrain hthe hclient, hif hnecessary, hto hkeep hher hfrom hleaving hthe hhospital. hThe hnurse hunderstands
hthat hrestraining hthis hclient hwould hbe hconsidered hwhich htype hof hcivil haction hby hthe hnurse?
A. Invasion hof hprivacy
Rationale: hInvasion hof hprivacy his hdefined has hfailure hto hrespect ha hclient’s hright hto hmanage htheir hown
haffairs.
This hsituation hdoes hnot hdescribe hinvasion hof hprivacy.
B. Assault
Rationale: hAssault his hdefined has hthreatening hto hinflict hinjury hon ha hclient hor han hattempt hto
hdo hharm. hThis hsituation hdoes hnot hdescribe hassault.
C. Battery
Rationale: hBattery his hdefined has hintentionally htouching ha hclient hwithout hher hconsent. hThis
hsituation hdoes hnot hdescribe hbattery.
D. False himprisonment
Rationale: hFalse himprisonment his hdetaining ha hclient hagainst hher hwill hto hseek hfreedom. hThe
hclient hhas hthe hright hto hrefuse htreatment hagainst hmedical hadvice hand hleave hthe
hhospital.
2. An hassistive hpersonnel h(AP) hreports ha hclient’s hvital hsigns has htympanic htemperature h37.1° hC
h(98.8° hF), hpulse h92/min, hrespiratory hrate h18/min, hand hBP h98/58 hmm hHg. hWhich hof hthe hfollowing
hvital hsigns hshould hthe hnurse hre-measure?
A. BP
Rationale: hA hnurse hwho his hsupervising han hAP's hwork his haccountable hfor hthe hwork hthat hthe hAP
hcompletes.
Therefore, hthe hnurse hshould hverify hanything hthat hseems hunusual. hThe hBP hthe hAP
hreported his hlow; htherefore, hthe hnurse hshould hverify hthat hthis hresult his haccurate
hbefore htaking hany hother hactions.
B. Respiratory hrate
Rationale: hThis hrespiratory hrate his hwithin hthe hexpected hreference hrange. hUnless hit hdeviates
hmarkedly hfrom hthe hclient’s husual hreadings, hthe hnurse hneed hnot htake hany haction
hat hthis htime.
C. Pulse hrate
Rationale: hThis hpulse hrate his hwithin hthe hexpected hreference hrange. hUnless hit hdeviates
hmarkedly hfrom hthe hclient’s husual hreadings, hthe hnurse hneed hnot htake hany haction
hat hthis htime.
D. Temperature
Rationale: hThis htemperature hreading his hwithin hthe hexpected hreference hrange. hUnless hit
hdeviates hmarkedly hfrom hthe hclient’s husual hreadings, hthe hnurse hneed hnot htake
hany haction hat hthis htime.
Created Page h
hon:05/14/2020 1
, Detailed hAnswer hKey
NR h226 hMay h2020 hExam h1
hWilliams
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, Detailed hAnswer hKey
NR h226 hMay h2020 hExam h1
hWilliams
3. A hnurse his hpreparing hto hinfuse ha h250-mL hunit hof hpacked hRBCs hover h2 hhr. hThe hdrop hfactor hof
hthe hmanual hIV htubing his h15 hgtts/mL. hThe hnurse hshould hadjust hthe hflow hrate hto hdeliver hhow
hmany hdrops hper hminute? h(Round hthe hanswer hto hthe hnearest hwhole hnumber. hUse ha hleading hzero
hif hit happlies. hDo hnot huse ha htrailing hzero.)
31 h gtt/min
Correct hRationale: hFollow hthese hsteps hto hcalculate hthe hinfusion hrate:
Step h1: hWhat his hthe hunit hof hmeasurement hthe hnurse hshould
hcalculate? hgtt/min hStep h2: hWhat his hthe hvolume hthe hnurse hshould
hinfuse? h250 hmL
Step h3: hWhat his hthe htotal hinfusion htime? h2 hhr
Step h4: hShould hthe hnurse hconvert hthe hunits hof hmeasurement? hYes h(min
hdoes hnot hequal hhr) h1 hhr/60 hmin h= h2 hhr/X hmin
X h= h120 hmin
Step h5: hSet hup han hequation hand hsolve hfor
hX. hVolume h(mL)/Time h(hr) hx hdrop hfactor
h(gtt/mL) h= hX h250 hmL/120 hmin hx h15
hgtt/mL h= hX hgtt/min
31.25 h= hX
Step h6: hRound hif hnecessary. h31.25 h= h31
Step h7: hReassess hto hdetermine hwhether hthe hamount hto hadminister hmakes
hsense. hIf hthe hprescription hreads hone h250-mL hunit hof hpacked hcells hto hinfuse
hIV hover h2 hhr, hit hmakes hsense hto hadminister h31 hgtt/min. hThe hnurse hshould
hadjust h hthe hmanual hIV hinfusion hto hdeliver hthe hpacked hRBCs hat h31 hgtt/min.
InCorrect hRationale: h Follow hthese hsteps hto hcalculate hthe hinfusion hrate:
Step h1: hWhat his hthe hunit hof hmeasurement hthe hnurse hshould
hcalculate? hgtt/min hStep h2: hWhat his hthe hvolume hthe hnurse hshould
hinfuse? h250 hmL
Step h3: hWhat his hthe htotal hinfusion htime? h2 hhr
Step h4: hShould hthe hnurse hconvert hthe hunits hof hmeasurement? hYes h(min
hdoes hnot hequal hhr)
1 hhr/60 hmin h= h2
hhr/X hmin hX h= h120
hmin
Step h5: hSet hup han hequation hand hsolve hfor
hX. hVolume h(mL)/Time h(hr) hx hdrop hfactor
h(gtt/mL) h= hX h250 hmL/120 hmin hx h15
hgtt/mL h= hX hgtt/min
31.25 h= hX
Step h6: hRound hif hnecessary. h31.25 h= h31
Step h7: hReassess hto hdetermine hwhether hthe hamount hto hadminister hmakes
hsense. hIf hthe hprescription hreads hone h250-mL hunit hof hpacked hcells hto
hinfuse hIV hover h2 hhr, hit hmakes hsense hto hadminister h31 hgtt/min. hThe hnurse
hshould hadjust h hthe hmanual hIV hinfusion hto hdeliver hthe hpacked hRBCs hat h31
hgtt/min.
4. A hcharge hnurse his hplanning ha hroom hassignment hfor ha hclient hwho hhas ha hproductive hcough, ha
hquestionable hchest hx-ray, hand ha hpositive hMantoux htest. hRoom h208 his ha hprivate, hnegative-pressure
hairflow hroom; hroom h212 his ha hsemi-private, hpositive-pressure hairflow hroom; h214 his ha hnegative-
pressure, hsemi-private hroom; hand hroom h216 his ha hprivate,
positive-pressure hairflow hroom. hTo hwhich hof hthe hfollowing hrooms hshould hthe hnurse hassign hthe hclient?
A. h 208
Rationale: hA hclient hwho hhas hor hmight hhave htuberculosis hrequires hairborne hprecautions. hThat
hmeans ha hprivate hroom hwith hnegative-pressure hairflow. hRoom h208 his hthe honly hone
Created Page h
hon:05/14/2020 3
, Detailed hAnswer hKey
NR h226 hMay h2020 hExam h1
hWilliams
hof hthese hoptions hthat hfits hthese hrequirements.
B. h 212
Rationale:
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