Nursing Elites

1. Before administration of a stat dose of potassium chloride IV for a client with hypokalemia, what is the most important action for the nurse?

• A. Ensure the IV is flowing freely
• B. Mix the medication thoroughly
• C. Check the client’s electrolyte levels
• D. Obtain a baseline ECG

Correct answer: A

Rationale: The most crucial action for the nurse before administering a stat dose of potassium chloride IV to a client with hypokalemia is to ensure the IV is flowing freely. A freely flowing IV is essential to safely and effectively deliver potassium chloride, helping to prevent infusion-related issues. Checking the client's electrolyte levels or obtaining a baseline ECG may be important but are not the most critical actions before administering the medication. Mixing the medication thoroughly is not applicable in this scenario as potassium chloride is typically provided ready to use.

2. The healthcare provider is preparing to administer a 1.2mL injection to a 4-year-old. Which is the best site to administer an IM injection?

• A. Vastus Lateralis
• B. Radial artery
• C. Dorsogluteal
• D. Rectus femoris

Correct answer: A

Rationale: The correct answer is A, Vastus Lateralis. The vastus lateralis site is recommended for IM injections in small children due to its large muscle mass, making it suitable for injections in pediatric patients. Choices B, C, and D are incorrect. The radial artery is not a site for IM injections; it is a site for arterial puncture. The dorsogluteal site is not recommended for children due to potential risks, such as injury to the sciatic nerve. The rectus femoris is not typically used for IM injections in children, as other sites like the vastus lateralis are more commonly preferred.

3. The nurse is preparing a client for discharge after a major surgical procedure. What is the priority instruction to include in the discharge teaching?

• A. Signs of infection to monitor for
• B. Pain management techniques
• C. Activity restrictions and safety measures
• D. All of the above

Correct answer: D

Rationale: The correct answer is D: All of the above. Providing comprehensive discharge instructions covering signs of infection to monitor for, pain management techniques, activity restrictions, and safety measures is crucial after a major surgical procedure. Each of these components plays a vital role in the client's recovery and well-being. It is important for the client to understand how to identify signs of infection, manage pain effectively, and adhere to activity restrictions to prevent complications and ensure a smooth recovery process. While each instruction is important on its own, combining all aspects into the discharge teaching ensures that the client has a holistic understanding of their post-operative care, empowering them to take charge of their health and know when to seek further assistance if needed. Choices A, B, and C are essential components of discharge teaching and should all be included to provide the client with comprehensive care instructions.

4. The nurse is caring for a client with increased intracranial pressure (ICP). Which position should the nurse avoid?

• A. Keeping the head of the bed elevated at 30 degrees
• B. Positioning the client in the prone position
• C. Placing the client in a lateral recumbent position
• D. Elevating the client's legs

Correct answer: B

Rationale: The correct answer is B: Positioning the client in the prone position. Placing the client in the prone position should be avoided in a client with increased intracranial pressure (ICP) as it can further raise ICP. The prone position can hinder venous return and increase pressure within the cranial vault, potentially worsening the client's condition. Keeping the head of the bed elevated at 30 degrees helps promote venous drainage and reduce ICP. Placing the client in a lateral recumbent position can also assist in reducing ICP by optimizing cerebral perfusion. Elevating the client's legs can help improve venous return and maintain adequate cerebral blood flow, making it a suitable positioning intervention for managing increased ICP.

5. The nurse is teaching a client with diabetes about foot care. Which instruction is most important to prevent complications?

• A. Soak feet in warm water daily
• B. Apply moisturizer between the toes
• C. Wear cotton socks
• D. Inspect feet daily for cuts or sores

Correct answer: D

Rationale: The correct answer is D: Inspect feet daily for cuts or sores. Daily foot inspection is crucial for clients with diabetes to detect early signs of injury or infection. Soaking feet in warm water daily (choice A) can lead to skin maceration, making the skin more susceptible to breakdown. Applying moisturizer between the toes (choice B) can increase moisture and the risk of fungal infections. While wearing cotton socks (choice C) is beneficial for diabetic foot care, it is not as crucial as daily foot inspections to prevent complications.

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