Nursing Elites

1. Following mitral valve replacement surgery, a client develops PVCs. The healthcare provider orders a bolus of Lidocaine followed by a continuous Lidocaine infusion at a rate of 2 mg/minute. The IV solution contains 2 grams of Lidocaine in 500 mL of D5W. The infusion pump delivers 60 microdrops/mL. What rate would deliver 4 mg of Lidocaine per minute?

• A. 60 microdrops/minute
• B. 20 microdrops/minute
• C. 30 microdrops/minute
• D. 40 microdrops/minute

Correct answer: A

Rationale: To calculate the rate needed to deliver 4 mg/minute of Lidocaine, first, convert 2 grams to milligrams: 2 grams = 2000 mg. Then, set up a ratio between the total amount of Lidocaine (2000 mg) and the total volume of IV solution (500 mL): 2000 mg / 500 mL = 4 mg / x mL. Solving for x, x = 1 mL. Since the infusion pump delivers 60 microdrops per mL, multiplying by 60 microdrops/mL gives the correct rate of 60 microdrops/minute. This rate ensures the desired 4 mg of Lidocaine is delivered per minute. Choices B, C, and D are incorrect as they do not align with the accurate calculation based on the provided information.

2. A nurse has just started her rounds delivering medication. A new patient on her rounds is a 4-year-old boy who is non-verbal. This child does not have any identification on. What should the nurse do?

• A. Contact the provider
• B. Ask the child to write their name on paper
• C. Ask a coworker about the identification of the child
• D. Ask the father who is in the room the child's name

Correct answer: D

Rationale: When encountering a non-verbal child without identification, it is appropriate for the nurse to ask the accompanying parent or guardian for the child's name. The father, being present in the room, can provide the necessary information. This ensures accurate identification to deliver the correct medication. Contacting the provider may cause unnecessary delays. Asking a non-verbal child to write their name is not feasible. Asking a coworker may not provide reliable identification as they may not have direct knowledge.

3. A 53-year-old patient is being treated for bleeding esophageal varices with balloon tamponade. Which nursing action will be included in the plan of care?

• A. Instruct the patient to cough every hour
• B. Monitor the patient for shortness of breath
• C. Verify the position of the balloon every 4 hours
• D. Deflate the gastric balloon if the patient reports nausea

Correct answer: B

Rationale: The correct nursing action for a patient with balloon tamponade for bleeding esophageal varices is to monitor the patient for shortness of breath. The most common complication of balloon tamponade is aspiration pneumonia. Additionally, if the gastric balloon ruptures, the esophageal balloon may slip upward and occlude the airway. Instructing the patient to cough every hour is incorrect as coughing increases the pressure on the varices and raises the risk of bleeding. Verifying the position of the balloon every 4 hours is unnecessary as it is typically done after insertion. Deflating the gastric balloon if the patient reports nausea is incorrect because deflating it may cause the esophageal balloon to occlude the airway, leading to complications. Therefore, monitoring for signs of respiratory distress is crucial in this situation.

4. During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute, and the client complains of periodic dizzy spells. The nurse instructs the client to:

• A. Increase fluids that are high in protein
• B. Restrict fluids
• C. Force fluids and reassess blood pressure
• D. Limit fluids to non-caffeine beverages

Correct answer: D

Rationale: In this scenario, the client with cardiomyopathy is exhibiting signs of orthostatic hypotension, which is characterized by a significant drop in systolic blood pressure (>15 mm Hg) and an increase in heart rate (>15%), along with dizziness. These symptoms suggest volume depletion, inadequate vasoconstrictor mechanisms, and autonomic insufficiency. The appropriate nursing intervention in this case is to force fluids and reassess blood pressure to address the underlying issue of volume depletion and improve hemodynamic stability. Choices A, B, and D are incorrect because increasing fluids high in protein, restricting fluids, or limiting fluids to non-caffeine beverages are not appropriate actions for a client experiencing orthostatic hypotension and signs of volume depletion.

5. The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is:

• A. Verify correct placement of the tube
• B. Check that the feeding solution matches the dietary order
• C. Aspirate gastric contents to determine the amount of the last feeding remaining in the stomach
• D. Ensure that the feeding solution is at room temperature

Correct answer: A

Rationale: The most crucial action for the nurse when preparing to administer enteral feeding via a nasogastric tube is to verify the correct placement of the tube. Proper placement of the tube is vital to prevent complications such as aspiration into the lungs. The definitive methods to confirm the position of the nasogastric tube include visualization through an x-ray or aspirating stomach contents and checking their pH (usually pH 1 to 5). Aspirated stomach content can also be tested for bilirubin to confirm placement in the stomach. Choice B, checking that the feeding solution matches the dietary order, is important for ensuring the correct nutrition is provided but is not as critical as verifying tube placement to prevent potential harm. Choice C, aspirating gastric contents to determine the amount of the last feeding remaining in the stomach, is a common nursing practice but is not the most crucial action when compared to ensuring correct tube placement. Choice D, ensuring that the feeding solution is at room temperature, is relevant for patient comfort and preventing thermal injury but is not as essential as confirming correct tube placement to prevent serious complications.

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