Set A rationales, items 6–10

Item 6 — Answer: 1.5 tablets

Why 1.5 is right: 0.075 mg is 75 micrograms, because milligrams become micrograms by multiplying by 1,000. The tablets are 50 micrograms and are scored. 75 divided by 50 is 1.5, which is one and a half tablets. Why 0.0015 tablets is wrong: this is 0.075 divided by 50, dividing milligrams by micrograms without converting. Born at CONVERT. Why 0.67 tablets is wrong: this is 50 divided by 75, the ratio inverted. Have on hand goes on the bottom, desired dose on top. Born at SET UP. Why 2 tablets is wrong: this is 1.5 rounded up to a whole tablet. The tablet is scored, so half is available, and rounding a dose upward without a reason is a medication error rather than a math error. Born at SOLVE.

The rule: convert before you divide.

Item 7 — Answer: 1, 3, 4, 5

Why 1 is right: premixed solutions eliminate the two errors that kill, which are adding potassium to a bag that is already infusing and failing to mix it so the client receives a concentrated bolus from the bottom of the bag. Why 3 is right: potassium is excreted renally. Giving it to a client who is not producing urine builds a level that cannot be lowered. Why 4 is right: potassium is a vesicant. It burns, it infiltrates, and an infusion pump is required so the rate cannot run away. Why 5 is right: rates above 10 mEq per hour carry enough arrhythmia risk that continuous cardiac monitoring becomes the standard, along with a setting that can respond. Why 2 is wrong: intravenous potassium is never given by push. Not slowly, not diluted in the syringe, not in an emergency. A push dose causes cardiac arrest. This is a fact about the route, and it is one of a small number of things on this exam that has no clinical exception. Why 6 is wrong: there is no reason to withhold dietary potassium from a client who was just found to be hypokalemic. It reverses the goal.

The rule: some routes are never used, and that is a fact, not a judgment.

Item 8 — Answer: 2, 4, 5, 1, 3

Why hand hygiene and gloves come first: it is the standard precaution that precedes contact with gastric contents, and it is first on every procedure sequence in this book. Why comparing external length comes second: the fastest evidence that a tube has migrated is that more or less of it is outside the client than there was at insertion, and it costs no equipment. Why aspirating comes third: you cannot test what you have not withdrawn, and the appearance of the aspirate is information in its own right. Why testing the pH comes fourth: pH is the bedside verification that the aspirate is gastric, and it is done on the aspirate you just obtained. Why flushing and beginning the feeding comes last: verification is complete before anything is instilled, and that ordering is the entire point of the item. Why the order 2, 4, 5, 3, 1 fails: it begins the feeding before the pH is read, which means the verification step was performed but not used. Why the order 2, 5, 1, 4, 3 fails: it aspirates before checking the external length, which is not dangerous, but it also puts the pH after the flush, and flushing with water changes the pH of what you would sample next.

The rule: verify before you instill.

Item 9 — Answers: [1] hypoglycemia, [2] cool moist skin with tremor and a glucose of 48 mg/dL

Why hypoglycemia is right: rapid-acting insulin was given at 0800 and no food followed it. Two and a half hours later, the client is diaphoretic, tremulous, irritable, cool, and tachycardic at a measured glucose of 48 mg/dL. The exposure, the timing, the signs, and the number all agree. Why hyperglycemia is wrong: a glucose of 48 mg/dL excludes it outright, and the skin in hyperglycemia is warm and dry, not cool and moist. Why diabetic ketoacidosis is wrong: it requires a high glucose, an acidosis, and ketones. Respirations here are 20 and unlabored, with no fruity odor. Why hyperosmolar hyperglycemic state is wrong: it is a very high glucose in an older adult with type 2 diabetes, developing over days, and none of that describes this client. Why deep rapid respirations with a fruity odor is wrong: those are Kussmaul respirations, which belong to ketoacidosis, and this client's respirations are unlabored. Why polyuria with dry mucous membranes is wrong: those are hyperglycemic osmotic findings, and nothing here documents them. Why a serum glucose above 600 mg/dL is wrong: the measured value is 48 mg/dL. Evidence has to come from the exhibit.

The rule: cold and clammy needs candy.

Item 10 — Answers, in row order: document and monitor, report now, report now, document and monitor, report now

Why the temperature is document and monitor: 100.2°F, falling from 101.8°F, is the treatment working. A fever that is trending down on day 2 of antibiotics is the expected course. Why the temperature is not report now: reporting improvement as a problem trains the team to stop reading your reports. Why the respiratory rate of 30 with accessory muscle use is report now: accessory muscle use is the finding that turns a number into work of breathing, and it says the client is compensating hard. Why it is not document and monitor: the client is spending reserve to hold that rate, and reserve runs out. Why the saturation of 87% on 2 liters per minute is report now: it is hypoxemia on supplemental oxygen, meaning the current therapy is failing. Why it is not document and monitor: 87% is below the threshold at which you continue with the current plan for any client. Why the productive cough with thick yellow sputum is document and monitor: this is the expected finding, and it is the row that decides the score. In pneumonia, a productive cough is the lung clearing itself, and purulent sputum is the disease, not a new development. Why it is not report now: nothing about it has changed, and reporting an expected finding as urgent buries the two rows that are. Why the systolic fall from 118 to 86 is report now: a 32 point fall over 4 hours in a client with an infection is the perfusion arm of sepsis. Why it is not document and monitor: this is the trend the entire row exists to catch.

The rule: expected findings are documented, not reported.

Set A close. Total your set A score out of 10. Note which two Client Needs subcategories your misses cluster in. Carry both, and the total, to page 76 before you start set B.

Margin note: "the wrong answer usually has a birthplace."

> Watch out on item 7: never by push. There is no version of this that is safe. > Memory hook: COLD AND CLAMMY, NEEDS SOME CANDY > → BOOK 06 · P4 and → BOOK 05 · P9

Takeaway. Every wrong calculation answer comes from a locatable step, and finding that step is worth more than getting the item right.