Nursing Elites

1. Which of the following findings contraindicate the use of haloperidol (Haldol) and warrant withholding the dose?

• A. Drowsiness, lethargy, and inactivity
• B. Dry mouth, nasal congestion, and blurred vision
• C. Rash, blood dyscrasias, severe depression
• D. Hyperglycemia, weight gain, and edema

Correct answer: C

Rationale: The correct answer is C: Rash, blood dyscrasias, and severe depression are serious side effects of haloperidol that necessitate withholding the dose and prompt further evaluation. Rash can indicate an allergic reaction, blood dyscrasias are serious blood disorders that can be life-threatening, and severe depression may worsen with haloperidol use. Choices A, B, and D are incorrect because drowsiness, lethargy, inactivity, dry mouth, nasal congestion, blurred vision, hyperglycemia, weight gain, and edema are common side effects of haloperidol that may not necessarily contraindicate its use but should be monitored and managed appropriately.

2. A client with chronic kidney disease is being assessed. Which laboratory value would be most concerning?

• A. Serum creatinine of 3.0 mg/dL
• B. Blood urea nitrogen (BUN) of 45 mg/dL
• C. Serum potassium of 6.5 mEq/L
• D. Hemoglobin of 10 g/dL

Correct answer: C

Rationale: In a client with chronic kidney disease, an elevated serum potassium level (hyperkalemia) is the most concerning finding. Hyperkalemia can lead to life-threatening cardiac dysrhythmias due to its effect on the electrical conduction system of the heart. Monitoring and managing serum potassium levels are crucial in patients with chronic kidney disease to prevent serious complications. While elevated serum creatinine (Choice A) and Blood Urea Nitrogen (BUN) levels (Choice B) indicate impaired kidney function, hyperkalemia poses an immediate risk of cardiac complications. Hemoglobin levels (Choice D) are typically lower in chronic kidney disease due to decreased erythropoietin production, but they do not present an immediate life-threatening risk like hyperkalemia.

3. The nurse receives a report that a client with an indwelling urinary catheter has an output of 150 mL for the previous 6-hour shift. Which intervention should the nurse implement first?

• A. Check the drainage tubing for a kink
• B. Review the intake and output record
• C. Notify the healthcare provider
• D. Give the client 8 oz of water to drink

Correct answer: A

Rationale: The correct answer is to check the drainage tubing for a kink. A kink in the tubing can obstruct urine flow, potentially causing the low output. By addressing this first, the nurse can ensure that there are no physical obstructions hindering urine drainage. Reviewing the intake and output record is important, but addressing a possible kink in the tubing takes precedence as it directly affects urine flow. Notifying the healthcare provider should be considered after assessing and resolving immediate issues. Giving the client water to drink may be appropriate, but addressing a kink in the tubing is the priority to ensure proper function of the urinary catheter.

4. The healthcare professional prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The infusion set delivers 10 drops per milliliter. The healthcare professional should regulate the IV to administer approximately how many drops per minute?

• A. 80
• B. 8
• C. 21
• D. 25

Correct answer: C

Rationale: To calculate the drops per minute for the IV infusion, first determine the total drops to be infused over 8 hours. 1,000 ml to be infused over 8 hours means 125 ml per hour (1000 ml / 8 hours = 125 ml/hr). Since the infusion set delivers 10 drops per ml, 125 ml/hr x 10 drops/ml = 1250 drops/hr. To find drops per minute, divide the drops per hour by 60 (minutes in an hour): 1250 drops/hr / 60 minutes = 20.83 drops/minute, which rounds up to 21 drops per minute (Option C). This rate ensures the correct infusion rate over 8 hours. Choices A, B, and D are incorrect calculations and do not provide the appropriate infusion rate needed to administer the IV over the specified time period.

5. A client with a body mass index (BMI) of 30 is seeking advice on the initial approach to a weight loss plan. What action should the nurse recommend?

• A. Plan meals with low carbohydrates and high protein
• B. Engage in strenuous activity for an hour daily
• C. Keep a record of daily food and beverage intake
• D. Participate in a group exercise class three times a week

Correct answer: C

Rationale: Keeping a food diary is an essential practice when starting a weight loss plan as it helps in tracking calorie intake, identifying eating patterns, and making informed decisions about dietary changes. Planning meals with low carbohydrates and high protein (Choice A) can be beneficial for some individuals, but keeping a food diary is more foundational. Engaging in strenuous daily activity (Choice B) may not be sustainable for everyone and could lead to burnout or injuries. Participating in a group exercise class (Choice D) is beneficial for fitness but may not address dietary habits, which are crucial for weight loss.

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