a50milliliter ml bolus of normal saline fluid is ordered bythe physician the physician wants it to infuse in 30 minutes the nurse should set the pump
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Nursing Elites

NCLEX-PN

2024 Nclex Questions

1. A 50-milliliter (ml) bolus of normal saline fluid is ordered by the physician. The physician wants it to infuse in 30 minutes. The nurse should set the pump rate at:

Correct answer: A

Rationale: To infuse a 50 ml bolus in 30 minutes, the rate should be calculated as follows: 50 ml / 30 min = 100 ml per hour. Therefore, the correct answer is to set the pump rate at 100 ml per hour for one hour. Choice A is the correct rate based on the calculation. Choices B, C, and D all provide incorrect rates that do not match the physician's order. Choice B would only deliver 30 ml in 30 minutes, not the ordered 50 ml. Choice C would deliver 120 ml in one hour, which is 20 ml more than ordered. Choice D would only provide 25 ml over 30 minutes, not the full 50 ml prescribed.

2. The licensed practical nurse is working with a registered nurse and a patient care assistant. Which of the following clients should be cared for by the registered nurse?

Correct answer: D

Rationale: The correct answer is a client 2 days post-thoracotomy because this client is the most critical and requires the expertise of a registered nurse. Clients A and B are stable and ready for discharge after their respective surgeries (appendectomy and thyroidectomy). Client C, who is 3 days post-splenectomy, is also stable enough to be cared for by a licensed practical nurse as they are in a stable condition and do not have immediate critical needs. Therefore, the registered nurse should care for the client 2 days post-thoracotomy due to the critical nature of the procedure and the immediate postoperative care required.

3. What is the purpose of a contract between a nurse and a client?

Correct answer: A

Rationale: The purpose of a contract between a nurse and a client is to specify the participation and responsibilities of both parties. It outlines the expectations, contributions, and duties of each party involved in the professional relationship. This ensures clarity and mutual understanding. Choice B is incorrect as contracts do not indicate feeling tone but rather focus on the professional aspects. Choice C is incorrect because while contracts are legally binding, their primary purpose is not to prevent premature termination but to establish guidelines. Choice D is incorrect as contracts focus more on responsibilities and participation rather than specific roles.

4. In performing a psychosocial assessment, the nurse begins by asking questions that encourage the client to describe problematic behaviors and situations. The next step is to elicit the client's

Correct answer: B

Rationale: In performing a psychosocial assessment, the nurse follows a structured approach, starting with encouraging the client to describe problematic behaviors and situations. The next step is to elicit the client's thoughts about what has been described. This step helps gather more assessment data and understand how the client interprets the situation. Asking about feelings, exploring possible solutions, and understanding the client's intent in sharing the description are more complex processes that come later in the assessment. Therefore, the correct next step after describing behaviors and situations is to inquire about the client's thoughts.

5. The client is admitted to the unit after a cholecystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because:

Correct answer: B

Rationale: Montgomery straps are used to secure dressings that require frequent changes due to the large amount of drainage usually present after a cholecystectomy. They are also beneficial for clients allergic to various types of tape. Answer A is incorrect as the client is not at higher risk of evisceration. Answer C is incorrect because Montgomery straps are not used to support drains. Answer D is incorrect as sutures or clips are typically used to secure the incision after gallbladder surgery, not Montgomery straps.

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