Question

A nurse is preparing to administer fluconazole 500 mg via intravenous (IV) infusion over 45 minutes. Available is fluconazole 500 mg in 100 mL 0.9% sodium chloride (NaCl). At what rate will the nurse set the infusion? 1 133 mL/hr (If needed, round the answer to the nearest whole number.)

Answer 1

Correct Answers:

133

Rationale :

✍️Total volume to infuse = 100 mL

✍️Total time = 45 minutes

✍️Convert minutes to hours

➡️45 minutes ÷ 60 = 0.75 hours

✍️Use the IV flow rate formula

➡️mL/hr=Total volume (mL)/Time (hr

➡️mL/hr=100 mL/0.75 hr

→133.3mL/hr

✍️Round to the nearest whole number

→ 133 mL/hr

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Answer 2

Correct Answers:

Bring the bladder scanner into the client's room.
Routinely assist the client to the bathroom.
Measure and record the client's urine output.

Rationale :

Bring the bladder scanner into the client’s room

🔷 This task is non-invasive and requires no clinical judgment, making it appropriate to delegate to UAP as part of workflow support.

🔷 Having the UAP promptly bring equipment reduces delays in care and allows the nurse to proceed quickly with the assessment and interpretation steps that only an RN should perform.

🔷 It supports efficiency and teamwork while preserving the RN’s time for tasks that involve assessment, planning, and decision-making.

🔷 The UAP can also ensure the device is plugged in, clean, and ready, reinforcing infection prevention and equipment readiness without crossing into assessment territory.

🔷 Delegating this step aligns with the principle that UAP perform task-oriented, predictable activities that have standardized outcomes.

🔷 The RN retains responsibility for operating the scanner, interpreting bladder volumes, and acting on results, preserving the boundary between data gathering support and nursing judgment.

Routinely assist the client to the bathroom

🔷 Assisting with toileting is an Activity of Daily Living (ADL) that is squarely within the UAP scope, requiring skills but not clinical interpretation.

🔷 Regular assisted toileting supports timed voiding/bladder training, which can reduce retention, promote comfort, and prevent overflow incontinence.

🔷 UAP involvement enhances safety and fall prevention by providing standby help, ensuring proper footwear, and using devices like gait belts when indicated.

🔷 Routine assistance also decreases skin integrity risks (e.g., moisture-associated skin damage) by helping the client void at intervals rather than delaying.

🔷 The UAP can observe and promptly report client changes (dizziness, difficulty initiating stream), while the RN synthesizes that information into the care plan.

🔷 Clear instructions (frequency, use call light, do not leave weak clients unattended) keep the activity predictable and low risk, matching safe delegation criteria.

Measure and record the client’s urine output

🔷 Tracking intake and output (I&O) is an objective data collection task that the UAP can reliably perform and document per facility policy.

🔷 Accurate measurement (using a urinal, hat, or graduated container) and timely recording give the RN essential trend data to evaluate renal perfusion and retention.

🔷 The UAP can also note basic characteristics (amount, time, unusual odor/color) and report variances, while the RN interprets significance (e.g., oliguria, hematuria).

🔷 Delegating I&O supports early identification of declining urine output, enabling the RN to intervene quickly (assessment, provider notification) when thresholds are crossed.

🔷 This task is stable, predictable, and standardized, meeting the criteria for safe delegation without requiring nursing judgment.

🔷 Reinforcing proper technique (avoid contamination, keep urinal level, zero the graduate) maintains accuracy and infection-prevention standards.

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Answer 3

Correct Answers:

Bring the bladder scanner into the client's room.
Routinely assist the client to the bathroom.
Measure and record the client's urine output.

Rationale :

Bring the bladder scanner into the client’s room

🔷 This task is non-invasive and requires no clinical judgment, making it appropriate to delegate to UAP as part of workflow support.

🔷 Having the UAP promptly bring equipment reduces delays in care and allows the nurse to proceed quickly with the assessment and interpretation steps that only an RN should perform.

🔷 It supports efficiency and teamwork while preserving the RN’s time for tasks that involve assessment, planning, and decision-making.

🔷 The UAP can also ensure the device is plugged in, clean, and ready, reinforcing infection prevention and equipment readiness without crossing into assessment territory.

🔷 Delegating this step aligns with the principle that UAP perform task-oriented, predictable activities that have standardized outcomes.

🔷 The RN retains responsibility for operating the scanner, interpreting bladder volumes, and acting on results, preserving the boundary between data gathering support and nursing judgment.

Routinely assist the client to the bathroom

🔷 Assisting with toileting is an Activity of Daily Living (ADL) that is squarely within the UAP scope, requiring skills but not clinical interpretation.

🔷 Regular assisted toileting supports timed voiding/bladder training, which can reduce retention, promote comfort, and prevent overflow incontinence.

🔷 UAP involvement enhances safety and fall prevention by providing standby help, ensuring proper footwear, and using devices like gait belts when indicated.

🔷 Routine assistance also decreases skin integrity risks (e.g., moisture-associated skin damage) by helping the client void at intervals rather than delaying.

🔷 The UAP can observe and promptly report client changes (dizziness, difficulty initiating stream), while the RN synthesizes that information into the care plan.

🔷 Clear instructions (frequency, use call light, do not leave weak clients unattended) keep the activity predictable and low risk, matching safe delegation criteria.

Measure and record the client’s urine output

🔷 Tracking intake and output (I&O) is an objective data collection task that the UAP can reliably perform and document per facility policy.

🔷 Accurate measurement (using a urinal, hat, or graduated container) and timely recording give the RN essential trend data to evaluate renal perfusion and retention.

🔷 The UAP can also note basic characteristics (amount, time, unusual odor/color) and report variances, while the RN interprets significance (e.g., oliguria, hematuria).

🔷 Delegating I&O supports early identification of declining urine output, enabling the RN to intervene quickly (assessment, provider notification) when thresholds are crossed.

🔷 This task is stable, predictable, and standardized, meeting the criteria for safe delegation without requiring nursing judgment.

🔷 Reinforcing proper technique (avoid contamination, keep urinal level, zero the graduate) maintains accuracy and infection-prevention standards.

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Answer 4

Correct Answers:

Inform the primary healthcare provider (PCP)

Rationale :

🔷Metformin combined with contrast dye poses a risk of lactic acidosis, especially if renal function is impaired by the dye.

🔷The nurse’s priority is to immediately notify the provider so that appropriate action can be taken, such as holding metformin for 48 hours post-procedure until renal function is confirmed stable.

🔷Simply checking blood sugar is insufficient, since the concern is renal clearance of metformin, not immediate glycemic control.

🔷Proceeding without intervention could lead to a life-threatening metabolic complication.

🔷This step aligns with safety protocols for diabetic clients undergoing radiologic studies with contrast.

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Answer 5

Correct Answers:

"Do you experience pain during urination?"

Rationale :

🟢Dysuria (pain or burning on urination) is one of the hallmark symptoms of a urinary tract infection (UTI).

🟢Other common UTI findings include frequency, urgency, suprapubic pain, and cloudy or foul-smelling urine.

🟢Asking about vaginal discharge or dietary changes does not directly assess for a UTI, and kidney stones are a separate condition with different symptoms.

🟢The nurse must focus on urinary symptoms to identify whether the client is showing signs of infection.

🟢Early recognition helps initiate timely treatment and prevents progression to pyelonephritis or sepsis.

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Answer 6

Correct Answers:

"Do you experience pain during urination?"

Rationale :

🟢Dysuria (pain or burning on urination) is one of the hallmark symptoms of a urinary tract infection (UTI).

🟢Other common UTI findings include frequency, urgency, suprapubic pain, and cloudy or foul-smelling urine.

🟢Asking about vaginal discharge or dietary changes does not directly assess for a UTI, and kidney stones are a separate condition with different symptoms.

🟢The nurse must focus on urinary symptoms to identify whether the client is showing signs of infection.

🟢Early recognition helps initiate timely treatment and prevents progression to pyelonephritis or sepsis.

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Answer 7

Correct Answers:

Epoetin alfa

Rationale :

🔴Clients with chronic renal failure often develop anemia due to decreased production of erythropoietin by the kidneys.

🔴Epoetin alfa is a synthetic form of erythropoietin that stimulates the bone marrow to produce red blood cells.

🔴A hemoglobin level of 7.5 g/dL is critically low, placing the client at risk for fatigue, hypoxia, and cardiac complications.

🔴Treating anemia in renal failure with epoetin alfa improves oxygen delivery, energy levels, and quality of life.

🔴This intervention is a standard part of renal anemia management alongside iron and folate supplementation.

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Answer 8

Correct Answers:

Epoetin alfa

Rationale :

🔴Clients with chronic renal failure often develop anemia due to decreased production of erythropoietin by the kidneys.

🔴Epoetin alfa is a synthetic form of erythropoietin that stimulates the bone marrow to produce red blood cells.

🔴A hemoglobin level of 7.5 g/dL is critically low, placing the client at risk for fatigue, hypoxia, and cardiac complications.

🔴Treating anemia in renal failure with epoetin alfa improves oxygen delivery, energy levels, and quality of life.

🔴This intervention is a standard part of renal anemia management alongside iron and folate supplementation.

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Answer 9

Correct Answers:

Palpitations
Temperature
Exophthalmos

Rationale :

Palpitations

🟢A heart rate of 144 bpm with palpitations indicates severe tachycardia, which requires immediate follow-up due to risk for dysrhythmias, heart failure, or cardiovascular collapse.

🟢 In the context of hyperthyroidism, this may represent thyroid storm, a life-threatening emergency where the metabolic rate accelerates dangerously.

🟢 Prompt recognition allows the nurse to prepare for interventions such as beta-blockers and continuous cardiac monitoring.

🟢 Without treatment, uncontrolled tachycardia can compromise cardiac output and perfusion.

🟢 This finding represents an acute safety risk requiring immediate action.

Temperature

🟢Dry, hot skin and elevated temperature are hallmark signs of severe hypermetabolism, again suggesting possible thyroid storm.

🟢Hyperthermia significantly increases oxygen demand and may precipitate multi-organ dysfunction if untreated.

🟢Immediate nursing interventions include rapid cooling measures, IV fluids, and provider notification.

🟢Fever in this context is not benign; it reflects uncontrolled thyroid hormone release and systemic instability.

🟢This requires urgent attention alongside cardiac symptoms.

Exophthalmos

🟢Exophthalmos is a significant finding associated with Graves’ disease, indicating chronic thyroid eye involvement.

🟢While not acutely life-threatening, it warrants immediate follow-up because it can cause exposure keratitis, corneal ulceration, or vision loss if untreated.

🟢Nursing interventions include artificial tears, eye protection, and elevating the head of the bed to reduce periorbital edema.

🟢Severe exophthalmos can progress to optic nerve compression, making it a priority follow-up.

🟢This finding reinforces the diagnosis of hyperthyroidism crisis in the client’s presentation.

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Answer 10

Correct Answers:

Cardiovascular system

Rationale :

🟢The client’s heart rate of 144 bpm with palpitations and elevated blood pressure (164/92 mm Hg) signals acute cardiovascular instability.

🟢Severe tachycardia in the context of hyperthyroidism/thyroid storm can quickly lead to dysrhythmias, high-output heart failure, or cardiac arrest if not addressed promptly.

🟢Although neurologic (restlessness), gastrointestinal (loose stools, increased hunger), and integumentary (hot skin) findings are important, the most immediate life-threatening risk is compromised cardiac function.

🟢Nursing priorities must follow the ABC framework (Airway, Breathing, Circulation), making cardiovascular stabilization the top concern.

🟢Interventions may include continuous cardiac monitoring, oxygen therapy, and administration of beta-blockers to control heart rate and reduce cardiac workload.

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QLexNursing

1 :
A nurse is preparing to administer fluconazole 500 mg via intravenous (IV) infusion over 45 minutes. Available is fluconazole 500 mg in 100 mL 0.9% sodium chloride (NaCl). At what rate will the nurse set the infusion? 1 133 mL/hr (If needed, round the answer to the nearest whole number.)

2 :
The nurse plans care for a client with urinary retention. What task(s) should the nurse plan to delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

3 :
The nurse plans care for a client with urinary retention. What task(s) should the nurse plan to delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

4 :
A nurse working in the radiology department is preparing a client who has diabetes mellitus for a procedure that requires the use of contrast dye. During the intake assessment, the client tells the nurse that they took their morning dose of metformin. What action should the nurse take?

5 :
The nurse cares for a client admitted to the emergency room. What question should the nurse ask the client to assess for signs of a urinary tract infection?

6 :
The nurse cares for a client admitted to the emergency room. What question should the nurse ask the client to assess for signs of a urinary tract infection?

7 :
A nurse planning care for a client with chronic renal failure and a hemoglobin of 7.5 g/dL. The nurse anticipates receiving a prescription for which medication?

8 :
A nurse planning care for a client with chronic renal failure and a hemoglobin of 7.5 g/dL. The nurse anticipates receiving a prescription for which medication?

9 :
Patient data.

Answer Options

10 :
Patient Data .

Answer Options

QLexNursing

1 : A nurse is preparing to administer fluconazole 500 mg via intravenous (IV) infusion over 45 minutes. Available is fluconazole 500 mg in 100 mL 0.9% sodium chloride (NaCl). At what rate will the nurse set the infusion? 1 133 mL/hr (If needed, round the answer to the nearest whole number.)

2 : The nurse plans care for a client with urinary retention. What task(s) should the nurse plan to delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

3 : The nurse plans care for a client with urinary retention. What task(s) should the nurse plan to delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

4 : A nurse working in the radiology department is preparing a client who has diabetes mellitus for a procedure that requires the use of contrast dye. During the intake assessment, the client tells the nurse that they took their morning dose of metformin. What action should the nurse take?

5 : The nurse cares for a client admitted to the emergency room. What question should the nurse ask the client to assess for signs of a urinary tract infection?

6 : The nurse cares for a client admitted to the emergency room. What question should the nurse ask the client to assess for signs of a urinary tract infection?

7 : A nurse planning care for a client with chronic renal failure and a hemoglobin of 7.5 g/dL. The nurse anticipates receiving a prescription for which medication?

8 : A nurse planning care for a client with chronic renal failure and a hemoglobin of 7.5 g/dL. The nurse anticipates receiving a prescription for which medication?

9 : Patient data.

Answer Options

10 : Patient Data .

Answer Options

1 :
A nurse is preparing to administer fluconazole 500 mg via intravenous (IV) infusion over 45 minutes. Available is fluconazole 500 mg in 100 mL 0.9% sodium chloride (NaCl). At what rate will the nurse set the infusion? 1 133 mL/hr (If needed, round the answer to the nearest whole number.)

2 :
The nurse plans care for a client with urinary retention. What task(s) should the nurse plan to delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

3 :
The nurse plans care for a client with urinary retention. What task(s) should the nurse plan to delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

4 :
A nurse working in the radiology department is preparing a client who has diabetes mellitus for a procedure that requires the use of contrast dye. During the intake assessment, the client tells the nurse that they took their morning dose of metformin. What action should the nurse take?

5 :
The nurse cares for a client admitted to the emergency room. What question should the nurse ask the client to assess for signs of a urinary tract infection?

6 :
The nurse cares for a client admitted to the emergency room. What question should the nurse ask the client to assess for signs of a urinary tract infection?

7 :
A nurse planning care for a client with chronic renal failure and a hemoglobin of 7.5 g/dL. The nurse anticipates receiving a prescription for which medication?

8 :
A nurse planning care for a client with chronic renal failure and a hemoglobin of 7.5 g/dL. The nurse anticipates receiving a prescription for which medication?

9 :
Patient data.

10 :
Patient Data .