Nursing Elites

1. A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the LPN/LVN set the client's intravenous infusion pump?

• A. 13 ml/hour
• B. 63 ml/hour
• C. 80 ml/hour
• D. 125 ml/hour

Correct answer: B

Rationale: To calculate the correct rate of infusion, divide the total volume by the total time: 250 ml / 4 hours = 62.5 ml/hour, which is rounded up to 63 ml/hour. This rate ensures the proper administration of the KCl over the 4-hour period. Choice A (13 ml/hour) is incorrect as it does not match the calculated rate. Choices C (80 ml/hour) and D (125 ml/hour) are also incorrect as they do not correspond to the calculated rate needed for the specified time frame.

2. A nurse in a long-term care facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure?

• A. When do you usually bathe, in the morning or evening?
• B. Do you prefer a bath or a shower?
• C. At what temperature do you prefer your bath water?
• D. Are you able to help with your hygiene care?

Correct answer: D

Rationale: The priority assessment question before beginning hygiene care for a new resident is determining if the resident is able to help with their hygiene care. This is essential to ensure the resident's safety during the procedure and prevent any potential injuries. Options A, B, and C, while relevant to providing personalized care, are not as critical as assessing the resident's ability to participate in their own hygiene care. Asking about the resident's ability to assist also promotes their independence and autonomy in self-care activities.

3. The healthcare provider is assessing a client with acute pancreatitis. Which finding is most concerning?

• A. Pain radiating to the back
• B. Blood pressure of 95/60 mmHg
• C. Elevated serum amylase
• D. Absent bowel sounds

Correct answer: B

Rationale: In acute pancreatitis, a low blood pressure of 95/60 mmHg is the most concerning finding as it may indicate hypovolemia or shock, which are critical conditions requiring immediate intervention. Pain radiating to the back is a common symptom of pancreatitis but is not as immediately life-threatening as hypotension. Elevated serum amylase levels and absent bowel sounds are typical findings in acute pancreatitis and may indicate pancreatic inflammation and gastrointestinal motility issues, respectively, but they are not as acutely concerning as hypotension.

4. A client with a history of coronary artery disease is experiencing chest pain. What is the priority action for the nurse to take?

• A. Administer oxygen via a nasal cannula.
• B. Measure the client's vital signs.
• C. Obtain a 12-lead ECG.
• D. Encourage the client to use pursed-lip breathing.

Correct answer: A

Rationale: Administering oxygen via a nasal cannula is the priority action for a client experiencing chest pain due to coronary artery disease. Oxygen therapy helps improve oxygenation, reduce myocardial workload, and relieve chest pain by increasing oxygen delivery to the heart muscle. While measuring vital signs, obtaining a 12-lead ECG, and encouraging pursed-lip breathing are important interventions, administering oxygen takes precedence in this situation to address the potential hypoxemia associated with chest pain in a client with a history of coronary artery disease.

5. In a mass casualty scenario at a child day care center, which child would the triage nurse prioritize for treatment last?

• A. An infant with intermittent bulging anterior fontanel between crying episodes
• B. A toddler with severe deep abrasions covering over 98% of the body
• C. A preschooler with 1 lower leg fracture and the other leg with an upper leg fracture
• D. A school-age child with singed eyebrows and hair on the arms

Correct answer: B

Rationale: In a mass casualty scenario, the triage nurse would prioritize the toddler with severe deep abrasions covering over 98% of the body for treatment last. This child is categorized as 'expectant' due to the extensive injuries, which are unlikely to be survivable even with immediate treatment. The other choices describe injuries that are serious but have a higher likelihood of survival with appropriate and timely intervention. The infant with an intermittent bulging anterior fontanel may have increased intracranial pressure requiring urgent evaluation, the preschooler with leg fractures can be stabilized and treated effectively, and the school-age child with singed hair likely has superficial burns which can be managed promptly.

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