Nursing Elites

1. The nurse needs to add a medication to a liter of 5% Dextrose in Water (D5W) that is already infusing into a client. At what location should the nurse inject the medication?

• A. Medication port
• B. IV drip chamber
• C. Y-site connector
• D. At the hub of the IV catheter

Correct answer: A

Rationale: The correct answer is the medication port. When adding medication to an already infusing IV solution, it should be done through the medication port to ensure direct delivery into the bloodstream without interrupting the primary IV line. Injecting the medication into the IV drip chamber, Y-site connector, or at the hub of the IV catheter can lead to dilution, inaccurate dosing, or potential blockages in the IV line, which can compromise the effectiveness of the medication and patient safety.

2. A client with a history of chronic kidney disease (CKD) is admitted with hyperkalemia. Which clinical finding is most concerning?

• A. Peaked T waves on the ECG
• B. Bradycardia
• C. Muscle weakness
• D. Decreased deep tendon reflexes

Correct answer: A

Rationale: Peaked T waves on the ECG are the most concerning finding in a client with hyperkalemia. Hyperkalemia can lead to serious cardiac complications, including arrhythmias and cardiac arrest. Peaked T waves are a classic ECG finding associated with hyperkalemia and indicate the need for immediate intervention. Bradycardia, muscle weakness, and decreased deep tendon reflexes can also be seen in hyperkalemia, but the presence of peaked T waves signifies a higher risk of cardiac events, making it the most concerning finding in this scenario.

3. When administering ceftriaxone sodium (Rocephin) intravenously to a client, what finding requires the most immediate intervention by the nurse?

• A. Stridor
• B. Nausea
• C. Headache
• D. Pruritus

Correct answer: A

Rationale: The correct answer is A: Stridor. Stridor is a high-pitched sound that indicates airway obstruction. When administering ceftriaxone sodium (Rocephin) intravenously, if the client develops stridor, it is a medical emergency requiring immediate intervention to maintain a patent airway. Nausea, headache, and pruritus are important to assess, but they do not pose an immediate threat to the client's airway and would not require the same level of urgent intervention as stridor.

4. The nurse is caring for a client who is postoperative following a thyroidectomy. Which assessment finding is most concerning?

• A. Slight difficulty swallowing
• B. Hoarse voice
• C. Positive Chvostek's sign
• D. Pain at the incision site

Correct answer: C

Rationale: A positive Chvostek's sign is the most concerning assessment finding as it suggests hypocalcemia, which is a potential complication following thyroidectomy. Hypocalcemia can lead to serious complications such as tetany and laryngospasm. Immediate intervention is required to prevent further complications. Choices A, B, and D are common post-thyroidectomy findings and are expected during the immediate postoperative period. Slight difficulty swallowing may be due to postoperative swelling, a hoarse voice may be temporary due to intubation trauma, and pain at the incision site is normal after surgery.

5. In caring for a client with a PCA infusion of morphine sulfate through the right cephalic vein, the nurse assesses that the client is lethargic with a blood pressure of 90/60 mm Hg, a pulse rate of 118 beats per minute, and a respiratory rate of 8 breaths per minute. What assessment should the nurse perform next?

• A. Note the appearance and patency of the client's peripheral IV site.
• B. Palpate the volume of the client's right radial pulse.
• C. Auscultate the client's breath sounds bilaterally.
• D. Observe the amount and dose of morphine in the PCA pump syringe.

Correct answer: D

Rationale: In this scenario, the client is presenting with signs of potential opioid overdose, such as lethargy, hypotension, tachycardia, and bradypnea. The next assessment the nurse should perform is to observe the amount and dose of morphine in the PCA pump syringe. This evaluation is crucial in determining if the client is receiving an excessive amount of morphine, leading to the observed symptoms. Checking the PCA pump syringe will provide essential information to address the client's condition promptly and prevent further complications. Choices A, B, and C are not the priority in this situation as they do not directly address the potential cause of the client's symptoms related to morphine administration.

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