Nursing Elites

1. The healthcare provider prescribes potassium chloride 25 mEq in 500 ml D5W to infuse over 6 hours. The available 20 ml vial of potassium chloride is labeled '10 mEq/5 ml.' How many ml of potassium chloride should the nurse add to the IV fluid?

• A. 12.5
• B. 5
• C. 10
• D. 20

Correct answer: B

Rationale: To prepare 25 mEq of potassium chloride for the infusion, the nurse should add 5 ml of the 10 mEq/5 ml solution. This concentration provides the required amount of potassium chloride without exceeding the needed volume. Choice A would result in 12.5 mEq, which exceeds the prescribed amount. Choices C and D are incorrect as they do not align with the correct calculation based on the vial concentration.

2. The healthcare provider believes that a client who frequently requests pain medication may have a substance abuse problem. Which intervention reflects the healthcare provider's value of client autonomy over veracity?

• A. Administer the prescribed analgesic when requested
• B. Refer the client to a substance abuse program
• C. Collaborate with the healthcare provider to provide a placebo
• D. Document the frequency of medication requests

Correct answer: A

Rationale: Administering the prescribed analgesic when requested is the most appropriate intervention that reflects the healthcare provider's value of client autonomy over veracity. This action respects the client's right to manage their pain and avoids deception. Referring the client to a substance abuse program (Choice B) assumes a diagnosis without evidence and does not respect the client's autonomy. Collaborating to provide a placebo (Choice C) would involve deception, which goes against the value of veracity. Documenting the frequency of medication requests (Choice D) is important for the client's care but does not directly address the issue of respecting client autonomy over veracity.

3. A young female adult wanders into the Emergency Department. She is disheveled and confused and states, 'My date must have put something in my drink. He took my car, and I think he raped me. I don't exactly remember, but I know he hurt me.' How should the nurse respond?

• A. Did you try to resist or fight back when you felt uncomfortable?
• B. He hurt you? Can you elaborate on what happened?
• C. It is okay to cry, but first, let's address your injuries and the situation.
• D. Yes, I can see. Tell me more about what you remember.

Correct answer: D

Rationale: The correct response is to encourage the patient to share more about what she remembers. This approach helps gather crucial information, supports the patient in a non-judgmental manner, and allows the nurse to provide appropriate care. Choice A has been revised to be more sensitive by asking about resistance when feeling uncomfortable rather than placing blame. Choice B has been adjusted to show empathy and request more details without questioning the patient's account. Choice C, although empathetic, does not address the immediate need to collect information and support the patient.

4. A 17-year-old adolescent is brought to the emergency department by both parents because the adolescent has been coughing and running a fever with flu-like symptoms for the past 24 hours. Which intervention should the nurse implement first?

• A. Obtain a chest X-ray per protocol.
• B. Place a mask on the client’s face.
• C. Assess the client’s temperature.
• D. Determine the client’s blood pressure

Correct answer: B

Rationale: The correct intervention for the nurse to implement first is to place a mask on the client's face. This is crucial to prevent the potential spread of infectious agents to others in the emergency department, considering the presenting symptoms of coughing and fever. Placing a mask helps in containing respiratory secretions and reducing the risk of airborne transmission. Assessing the client’s temperature or blood pressure can be done after ensuring infection control measures. Obtaining a chest X-ray would be a secondary intervention once immediate infection control is addressed.

5. What is the primary focus of postoperative nursing care for the client with colon trauma?

• A. Monitoring for elevated coagulation studies
• B. Observation for and prevention of fistulas
• C. Monitoring for signs of hyponatremia
• D. Observation for and prevention of infection

Correct answer: D

Rationale: The correct answer is D: Observation for and prevention of infection. Postoperative nursing care for a client with colon trauma primarily focuses on preventing infections. Clients with colon trauma are at high risk for infections due to the disruption of the intestinal barrier. Monitoring for signs of infection, maintaining proper wound care, administering antibiotics as prescribed, and implementing strict aseptic techniques are essential in preventing postoperative infections. Choices A, B, and C are incorrect because elevated coagulation studies, fistulas, and hyponatremia are not the primary concerns in the immediate postoperative period for a client with colon trauma.

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