Nursing Elites

1. A client is receiving intravenous potassium chloride for hypokalemia. Which action should the nurse take to prevent complications during the infusion?

• A. Administer the infusion rapidly
• B. Monitor the infusion site for signs of infiltration
• C. Use a syringe pump for the infusion
• D. Flush the IV line with normal saline before starting the infusion

Correct answer: B

Rationale: The correct action to prevent complications during the infusion of potassium chloride is to monitor the infusion site for signs of infiltration. Rapid administration can lead to adverse effects, including cardiac arrhythmias. Using a syringe pump is not typically necessary for this infusion. Flushing the IV line with normal saline is a good practice but not directly related to preventing complications specifically during the infusion of potassium chloride.

2. Which of the following is a priority assessment for a client receiving intravenous vancomycin?

• A. Respiratory rate
• B. Blood pressure
• C. Urine output
• D. Hearing acuity

Correct answer: D

Rationale: The correct answer is D, Hearing acuity. Vancomycin is known to cause ototoxicity, which can result in hearing loss. Monitoring the client's hearing acuity is crucial to detect any early signs of ototoxicity. Assessing respiratory rate, blood pressure, and urine output are important assessments in general patient care but are not the priority when specifically monitoring for vancomycin-induced ototoxicity.

3. Which signs/symptoms would be considered classical signs of meningeal irritation?

• A. Positive Kernig sign, diarrhea, and headache
• B. Negative Brudzinski sign, positive Kernig sign, and irritability
• C. Positive Brudzinski sign, positive Kernig sign, and photophobia
• D. Negative Kernig sign, vomiting, and fever

Correct answer: C

Rationale: The correct answer is C: Positive Brudzinski sign, positive Kernig sign, and photophobia are considered classical signs of meningeal irritation. The Kernig sign is positive when the leg is extended at the knee and then raised, resulting in pain and resistance. The Brudzinski sign is positive when flexing the neck causes flexion of the hips and knees due to meningeal irritation. Photophobia, or sensitivity to light, is a common symptom due to meningeal inflammation. Choices A, B, and D are incorrect because they do not include the classic signs associated with meningeal irritation.

4. When planning care for a client newly diagnosed with open-angle glaucoma, the nurse identifies a priority nursing problem of visual sensory/perceptual alterations. This problem is based on which etiology?

• A. Limited eye movement.
• B. Decreased peripheral vision.
• C. Blurred distance vision.
• D. Photosensitivity.

Correct answer: B

Rationale: The correct answer is B: Decreased peripheral vision. In open-angle glaucoma, decreased peripheral vision is a characteristic symptom resulting from increased intraocular pressure. This visual impairment can lead to sensory/perceptual alterations. Choice A, limited eye movement, is not directly associated with the pathophysiology of open-angle glaucoma. Choice C, blurred distance vision, is more commonly seen in conditions like myopia or presbyopia. Choice D, photosensitivity, is not a typical manifestation of open-angle glaucoma and is more commonly associated with conditions like migraines or certain medications.

5. The nurse is reviewing blood pressure readings for a group of clients on a medical unit. Which client is at the highest risk for complications related to hypertension?

• A. Post-menopausal Caucasian female who overeats and is 20% above her ideal body weight.
• B. Young adult Hispanic female who has hemoglobin at 11 g/dl (110 g/L) and drinks beer daily.
• C. Older adult who consumes a diet of smoked, cured, and pickled foods.
• D. Middle-aged African-American male who has a serum creatinine level of 2.9 mg/dL (256.4 micromol/L).

Correct answer: D

Rationale: The correct answer is D. An elevated serum creatinine level indicates kidney damage, which significantly increases the risk of complications from hypertension. High blood pressure can damage the kidneys over time, leading to impaired kidney function. Choices A, B, and C do not directly correlate with increased risk of complications related to hypertension. Choice A focuses on obesity and overeating, Choice B on anemia and alcohol consumption, and Choice C on a diet high in sodium and nitrates, none of which are as directly related to hypertension complications as kidney damage.

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