1. A nurse on a pediatric floor is teaching a newly licensed nurse about iv therapy. Which of
the following information should the nurse include?
a. Perform range of motion exercises on the extremity containing the IV site.
b. Shave the client's hair if the IV is to be placed in the scalp.
c. IV sites can be placed in the lower extremities up to the age of 2 years.
d. Monitor the IV site, tubing, and connections every 4 hr. - ANSWER a. Perform range of
motion exercises on the extremity containing the IV site.
The nurse should instruct the newly licensed nurse to perform range of motion exercises on
the client's extremity that contains the IV site.
2. A nurse is caring for a client who has a prescription to receive one unit of packed red
blood cells. The clients blood type is AB+, and the nurse receives a unit of A- blood from the
blood bank. Which of the following actions should the nurse take?
a. Return the blood unit as it is not compatible with the client's blood type.
b. Stay with the client for 15 min prior to starting the blood transfusion.
c. Verify the unit of blood with another nurse.
d. Prime the blood tubing with 0.45% sodium chloride - ANSWER c. Verify the unit of
blood with another nurse.
The unit of blood is compatible with the client's blood type. However, the nurse should en-
sure that the blood unit had been verified by two nurses before initiating the transfusion.
1
,3. A nurse is caring for an older adult client who is experiencing dehydration. The nurse
should identify that which of the following factors increases the risk for dehydration in older
adult clients? (Select all that apply.)
a. Decreased kidney function
b. Decreased thirst response
c. Decreased total body fluid
d. Eating watermelon daily
e. Eating cucumbers with each meal - ANSWER a. Decreased kidney function
b. Decreased thirst response
c. Decreased total body fluid
Decreased kidney function is correct. The nurse should identify that an older adult client
who has decreased kidney function is at an increased risk for dehydration.
Decreased thirst response is correct. The nurse should expect that an older adult client who
has a decreased thirst response might not drink enough fluids daily, which puts them at in-
creased risk for dehydration.
Decreased total body fluid is correct. The nurse should expect that an older adult client who
has decreased total body fluid to be at increased risk for dehydration.
Eating watermelon daily is incorrect. Foods with high water content such as watermelon
help rehydrate the client and decrease the risk for dehydration.
Eating cucumbers with each meal is incorrect. Foods with high water content such as cucum-
bers help rehydrate the client and decrease the risk for dehydration.
4. A nurse is preparing to administer 4,200 ml of intravenous fluids to a client to infuse over
24 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to
2
, the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) - AN-
SWER 175
Follow these steps to calculate the infusion rate using the Ratio and Proportion or Desired
Over Have method of calculation:
Step 1: What is the unit of measurement the nurse should calculate? mL/hr
Step 2: What is the volume the nurse should infuse? 4200 mL
Step 3: What is the total infusion time? 24 hr
Step 4: Should the nurse convert the units of measurement? No
Step 5: Set up an equation and solve for X.
Volume (mL)X mL/hr = Time (hr)
4200 mLX mL/hr = 24 hr
X mL/hr = 175 mL/hr
Step 6: Round if necessary.
Step 7: Determine if the amount to administer makes sense. If the prescription reads 4200
mL of fluids IV to infuse over 24 hr, it makes sense to administer 175 mL/hr. The nurse
should set the IV pump to deliver 4200 mL of fluids IV at 175 mL/hr.
Follow these steps to calculate the infusion rate using the Dimensional Analysis method of
calculation:
Step 1: What is the unit of measurement the nurse should calculate? (Place the unit of
measure being calculated on the left side of the equation.)
X mL/hr =
Step 2: Determine the ratio that contains the same unit as the unit being calculated. (Place
the ratio on the right side of the equation, ensuring that the unit in the numerator matches
the unit being calculated.)
4200 mLX mL/hr = 24 hr
Step 3: Place any remaining ratios that are relevant to the item on the right side of the equa-
tion, along with any needed conversion factors, to cancel out unwanted units of measure-
ment.
4200 mLX mL/hr = 24 hr
Step 4: Solve for X.
3
the following information should the nurse include?
a. Perform range of motion exercises on the extremity containing the IV site.
b. Shave the client's hair if the IV is to be placed in the scalp.
c. IV sites can be placed in the lower extremities up to the age of 2 years.
d. Monitor the IV site, tubing, and connections every 4 hr. - ANSWER a. Perform range of
motion exercises on the extremity containing the IV site.
The nurse should instruct the newly licensed nurse to perform range of motion exercises on
the client's extremity that contains the IV site.
2. A nurse is caring for a client who has a prescription to receive one unit of packed red
blood cells. The clients blood type is AB+, and the nurse receives a unit of A- blood from the
blood bank. Which of the following actions should the nurse take?
a. Return the blood unit as it is not compatible with the client's blood type.
b. Stay with the client for 15 min prior to starting the blood transfusion.
c. Verify the unit of blood with another nurse.
d. Prime the blood tubing with 0.45% sodium chloride - ANSWER c. Verify the unit of
blood with another nurse.
The unit of blood is compatible with the client's blood type. However, the nurse should en-
sure that the blood unit had been verified by two nurses before initiating the transfusion.
1
,3. A nurse is caring for an older adult client who is experiencing dehydration. The nurse
should identify that which of the following factors increases the risk for dehydration in older
adult clients? (Select all that apply.)
a. Decreased kidney function
b. Decreased thirst response
c. Decreased total body fluid
d. Eating watermelon daily
e. Eating cucumbers with each meal - ANSWER a. Decreased kidney function
b. Decreased thirst response
c. Decreased total body fluid
Decreased kidney function is correct. The nurse should identify that an older adult client
who has decreased kidney function is at an increased risk for dehydration.
Decreased thirst response is correct. The nurse should expect that an older adult client who
has a decreased thirst response might not drink enough fluids daily, which puts them at in-
creased risk for dehydration.
Decreased total body fluid is correct. The nurse should expect that an older adult client who
has decreased total body fluid to be at increased risk for dehydration.
Eating watermelon daily is incorrect. Foods with high water content such as watermelon
help rehydrate the client and decrease the risk for dehydration.
Eating cucumbers with each meal is incorrect. Foods with high water content such as cucum-
bers help rehydrate the client and decrease the risk for dehydration.
4. A nurse is preparing to administer 4,200 ml of intravenous fluids to a client to infuse over
24 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to
2
, the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) - AN-
SWER 175
Follow these steps to calculate the infusion rate using the Ratio and Proportion or Desired
Over Have method of calculation:
Step 1: What is the unit of measurement the nurse should calculate? mL/hr
Step 2: What is the volume the nurse should infuse? 4200 mL
Step 3: What is the total infusion time? 24 hr
Step 4: Should the nurse convert the units of measurement? No
Step 5: Set up an equation and solve for X.
Volume (mL)X mL/hr = Time (hr)
4200 mLX mL/hr = 24 hr
X mL/hr = 175 mL/hr
Step 6: Round if necessary.
Step 7: Determine if the amount to administer makes sense. If the prescription reads 4200
mL of fluids IV to infuse over 24 hr, it makes sense to administer 175 mL/hr. The nurse
should set the IV pump to deliver 4200 mL of fluids IV at 175 mL/hr.
Follow these steps to calculate the infusion rate using the Dimensional Analysis method of
calculation:
Step 1: What is the unit of measurement the nurse should calculate? (Place the unit of
measure being calculated on the left side of the equation.)
X mL/hr =
Step 2: Determine the ratio that contains the same unit as the unit being calculated. (Place
the ratio on the right side of the equation, ensuring that the unit in the numerator matches
the unit being calculated.)
4200 mLX mL/hr = 24 hr
Step 3: Place any remaining ratios that are relevant to the item on the right side of the equa-
tion, along with any needed conversion factors, to cancel out unwanted units of measure-
ment.
4200 mLX mL/hr = 24 hr
Step 4: Solve for X.
3
