Nursing Elites

1. A client in the emergency department is severely dehydrated and is prescribed 3 L of intravenous fluid over 6 hours. At what rate (mL/hr) should the nurse set the intravenous pump to infuse the fluids? (Record your answer using a whole number.)

• A. 500 mL/hr
• B. 400 mL/hr
• C. 550 mL/hr
• D. 600 mL/hr

Correct answer: A

Rationale: To calculate the rate of the intravenous pump, divide the total volume of fluid (3 L = 3000 mL) by the total time in hours (6 hours), which equals 500 mL/hr. The correct answer is A. Choice B (400 mL/hr) is incorrect as it would result in a slower infusion rate. Choice C (550 mL/hr) and Choice D (600 mL/hr) are incorrect as they would result in a faster infusion rate, exceeding the prescribed amount of fluid to be infused over 6 hours.

2. The nurse is caring for a 70-kg patient who is receiving gentamicin (Garamycin) 85 mg 4 times daily. The patient reports experiencing ringing in the ears. The nurse will contact the provider to discuss

• A. decreasing the dose to 50 mg QID.
• B. giving the dose 3 times daily.
• C. obtaining a serum drug level.
• D. ordering a hearing test.

Correct answer: C

Rationale: When a patient receiving gentamicin (Garamycin) reports experiencing ringing in the ears, it is crucial to consider the possibility of ototoxicity. Ototoxicity is a known adverse effect of aminoglycosides. The appropriate action for the nurse in this situation is to contact the provider to discuss obtaining a serum drug level. This is important to assess the drug concentration in the patient's blood, which can help determine if the ringing in the ears is related to the medication. Decreasing the dose or changing the dosing frequency without assessing the serum drug level may not address the underlying issue and could potentially lead to suboptimal treatment. Ordering a hearing test may be necessary at a later stage if the serum drug level indicates a concern. Therefore, option C, obtaining a serum drug level, is the most appropriate action to take in this scenario.

3. A client with overflow incontinence needs assistance with elimination. What intervention should the nurse include in the plan of care?

• A. Stroke the medial aspect of the thigh.
• B. Use intermittent catheterization.
• C. Provide digital anal stimulation.
• D. Use the Valsalva maneuver.

Correct answer: D

Rationale: In clients with overflow incontinence, the voiding reflex arc is impaired. The Valsalva maneuver, which involves holding the breath and bearing down as if to defecate, can help initiate voiding by applying mechanical pressure. Options A and C (stroking the thigh or anal stimulation) rely on an intact reflex arc to trigger elimination and are not effective for clients with overflow incontinence. Intermittent catheterization (Option B) is a last resort due to the high risk of infection and should only be considered if other interventions fail.

4. A client has undergone insertion of a permanent pacemaker. When developing a discharge teaching plan, the nurse writes a goal of, 'The client will verbalize symptoms of pacemaker failure.' Which symptoms are most important to teach the client?

• A. Facial flushing.
• B. Fever.
• C. Pounding headache.
• D. Feelings of dizziness.

Correct answer: D

Rationale: The correct answer is 'D: Feelings of dizziness.' Feelings of dizziness may occur as a result of a decreased heart rate, leading to decreased cardiac output, which can be an indication of pacemaker failure. Teaching the client to recognize symptoms of decreased cardiac output, like dizziness, is crucial for early detection of pacemaker malfunction. Choices A, B, and C are less specific to pacemaker failure and are not commonly associated with this condition. Facial flushing, fever, and pounding headache are not typical signs of pacemaker failure and are not directly related to cardiac output, making them less relevant for teaching the client about pacemaker failure.

5. A client with type 1 diabetes mellitus has a blood glucose level of 620 mg/dL. After the nurse calls the physician to report the finding and monitors the client closely for:

• A. Metabolic acidosis
• B. Metabolic alkalosis
• C. Respiratory acidosis
• D. Respiratory alkalosis

Correct answer: A

Rationale: In the scenario described, a client with a blood glucose level of 620 mg/dL and type 1 diabetes mellitus is at risk of developing metabolic acidosis. In type 1 diabetes, the lack of sufficient circulating insulin leads to an increase in blood glucose levels. As the body cells utilize all available glucose, the breakdown of fats for energy results in the production of ketones, leading to metabolic acidosis. Metabolic alkalosis, respiratory acidosis, and respiratory alkalosis are not typically associated with uncontrolled type 1 diabetes. Metabolic alkalosis is more commonly linked to conditions such as vomiting or excessive diuretic use, while respiratory acidosis and respiratory alkalosis are related to respiratory system imbalances in carbon dioxide levels.

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