Nursing Elites

1. A client is receiving IV moderate sedation with midazolam and has a respiratory rate of 9/min. What should the nurse do?

• A. Place the client in a prone position
• B. Implement positive pressure ventilation
• C. Perform nasopharyngeal suctioning
• D. Administer flumazenil

Correct answer: D

Rationale: The correct answer is D: Administer flumazenil. Flumazenil is the reversal agent for midazolam, a benzodiazepine, and should be administered to counteract respiratory depression. Placing the client in a prone position (choice A) could further compromise their breathing. Implementing positive pressure ventilation (choice B) is not indicated as the first step when dealing with respiratory depression due to sedation. Performing nasopharyngeal suctioning (choice C) is not appropriate in this situation where the client is experiencing respiratory depression due to medication sedation.

2. A nurse is preparing to administer lactated Ringer's (LR) 1,000 mL IV to infuse over 8 hr. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?

• A. 19 gtt/min
• B. 20 gtt/min
• C. 21 gtt/min
• D. 22 gtt/min

Correct answer: C

Rationale: Calculation: 1000 mL / 480 minutes × 10 gtt/mL = 20.83, rounded to 21 gtt/min. This ensures proper IV fluid administration over the prescribed time. Choice C is the correct answer as it reflects the accurate calculation based on the given parameters. Choice A is incorrect because it does not accurately calculate the infusion rate. Choice B is incorrect as it does not consider the precise calculation required. Choice D is incorrect as it deviates from the correct calculation.

3. A nurse is assessing a client who has a sodium level of 122 mEq/L. Which of the following findings should the nurse expect?

• A. Decreased deep tendon reflexes
• B. Positive Trousseau’s sign
• C. Hypoactive bowel sounds
• D. Sticky mucous membranes

Correct answer: A

Rationale: A sodium level of 122 mEq/L indicates hyponatremia, which is characterized by decreased deep tendon reflexes. Hyponatremia leads to neurological symptoms such as altered reflexes. Choices B, C, and D are not typically associated with hyponatremia. Positive Trousseau’s sign is related to hypocalcemia, hypoactive bowel sounds can be seen in paralytic ileus or decreased peristalsis, and sticky mucous membranes are not specific findings related to sodium imbalances.

4. A client with a history of seizures is being cared for by a nurse. Which of the following interventions should the nurse prioritize?

• A. Ensure the environment is safe
• B. Administer medications as prescribed
• C. Monitor for signs of infection
• D. Educate the client about triggers

Correct answer: A

Rationale: The nurse should prioritize ensuring the environment is safe for a client with a history of seizures. This intervention is crucial to prevent injury during a seizure. Administering medications as prescribed is important but ensuring a safe environment takes precedence to prevent harm. Monitoring for signs of infection and educating the client about triggers are also essential aspects of care but are not the priority when considering the immediate safety of the client during a seizure.

5. A nurse is assessing a client who has a history of atrial fibrillation and is receiving warfarin. Which of the following laboratory values should the nurse monitor to determine the effectiveness of the warfarin?

• A. Platelet count
• B. International normalized ratio (INR)
• C. Bleeding time
• D. Partial thromboplastin time (PTT)

Correct answer: B

Rationale: The correct answer is B: International normalized ratio (INR). The INR is used to monitor the effectiveness of warfarin therapy. A higher INR indicates a longer time it takes for the blood to clot, which is desirable in patients receiving warfarin to prevent blood clots. Platelet count (Choice A) assesses the number of platelets in the blood and is not directly related to warfarin therapy. Bleeding time (Choice C) evaluates the time it takes for a person to stop bleeding after a standardized wound, but it is not specific to monitoring warfarin effectiveness. Partial thromboplastin time (PTT) (Choice D) is more commonly used to monitor heparin therapy, not warfarin.

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