Nursing Elites

1. A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client's intravenous infusion pump?

• A. 13 ml/hour.
• B. 63 ml/hour.
• C. 80 ml/hour.
• D. 125 ml/hour.

Correct answer: B

Rationale: The correct calculation involves dividing the total volume by the total time. In this case, 250 ml/4 hours = 63 ml/hour. The dose of KCl is not used in the calculation as the focus is on the rate of infusion over the specified time period. Choice A (13 ml/hour) is incorrect as it does not result from the correct calculation. Choice C (80 ml/hour) and Choice D (125 ml/hour) are also incorrect calculations and do not match the correct rate of infusion required.

2. The census on the unit is 90 percent, and there are no private rooms available. An elderly client with influenza is admitted. Which of the following rooms would it be appropriate to assign this client?

• A. A double room with a client admitted for impetigo.
• B. A double room with another client with the same diagnosis.
• C. A four-bed room with three clients who have had orthopedic surgery.
• D. A double room with an elderly client with a diagnosis of chickenpox.

Correct answer: B

Rationale: When a private room is not an option, the best choice is to assign the elderly client with influenza to a double room with another client diagnosed with the same condition. This is ideal as droplet precautions would likely already be in place for the other client, reducing the risk of spreading the infection to other clients in the unit. Choice A is not appropriate as impetigo does not require the same precautions as influenza. Choice C is not ideal as orthopedic surgery does not involve respiratory precautions. Choice D is incorrect because chickenpox requires airborne precautions, which could pose a risk to the elderly client with influenza.

3. The healthcare professional is monitoring a client receiving IV potassium chloride. Which assessment finding should prompt the healthcare professional to immediately stop the infusion?

• A. The client reports pain at the IV site
• B. The client’s heart rate is irregular
• C. The client has swelling at the IV site
• D. The client’s blood pressure is elevated

Correct answer: B

Rationale: An irregular heart rate is a critical sign of hyperkalemia, a serious condition that can lead to life-threatening cardiac arrhythmias. Stopping the infusion promptly is crucial to prevent further complications. The healthcare professional should inform the healthcare provider immediately for further evaluation and management. Choice A is incorrect because pain at the IV site is common and may not necessitate stopping the infusion. Choice C is incorrect as swelling at the IV site may indicate a local reaction but is not a reason to stop the infusion. Choice D is incorrect as an elevated blood pressure alone is not a direct indication to stop the infusion of IV potassium chloride.

4. The mental health nurse plans to discuss a client's depression with the health care provider in the emergency department. There are two clients sitting across from the emergency department desk. Which nursing action is best?

• A. Only refer to the client by gender.
• B. Identify the client only by age.
• C. Avoid using the client's name.
• D. Discuss the client another time.

Correct answer: D

Rationale: The best nursing action is to discuss the client another time. When discussing a client's confidential information, it is essential to ensure privacy and confidentiality. Given the presence of other clients in the immediate vicinity, it is inappropriate to discuss personal details about a client's condition openly. Waiting for a more private setting is crucial to uphold the client's right to privacy and confidentiality. Choices A, B, and C are not appropriate because referring to the client only by gender, age, or avoiding the client's name does not address the issue of discussing confidential information in a public setting, which compromises the client's privacy and confidentiality.

5. A client becomes angry while waiting for a supervised break to smoke a cigarette outside and states, 'I want to go outside now and smoke. It takes forever to get anything done here!' Which intervention is best for the nurse to implement?

• A. Encourage the client to use a nicotine patch.
• B. Reassure the client that it is almost time for another break.
• C. Have the client leave the unit with another staff member.
• D. Review the schedule of outdoor breaks with the client.

Correct answer: D

Rationale: When a client becomes angry while waiting for a supervised break, it is essential to address their concerns effectively. Reviewing the schedule of outdoor breaks with the client provides concrete information, helps manage the client's expectations, and may alleviate their frustration. This intervention promotes transparency and empowers the client by clarifying the timing of their desired break, fostering a therapeutic and collaborative nurse-client relationship. Encouraging the client to use a nicotine patch (Choice A) does not address the client's immediate frustration with the break schedule. Reassuring the client about another break (Choice B) may temporarily placate them but does not address the underlying issue. Having the client leave the unit with another staff member (Choice C) may not be feasible or appropriate at that moment and does not address the client's concerns.

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