Nursing Elites

1. A nurse is caring for a client receiving IV vancomycin. The nurse notes flushing of the client's neck and chest. Which of the following actions should the nurse take?

• A. Stop the infusion
• B. Document the findings as a harmless reaction
• C. Slow the infusion rate
• D. Administer diphenhydramine

Correct answer: C

Rationale: The correct action for the nurse to take when a client receiving IV vancomycin shows flushing of the neck and chest is to slow the infusion rate. Flushing is a common sign of Red Man Syndrome, which is associated with rapid infusions of vancomycin. Slowing down the infusion rate can help prevent further flushing and the development of Red Man Syndrome. Stopping the infusion (Choice A) may be too drastic if the symptoms are mild and can be managed by slowing the rate. Documenting the findings as a harmless reaction (Choice B) is incorrect because flushing should be addressed promptly to prevent complications. Administering diphenhydramine (Choice D) is not the initial or best intervention for flushing associated with vancomycin; slowing the infusion rate is the priority.

2. A nurse is preparing to administer potassium chloride IV to a client. Which of the following actions should the nurse take to prevent complications?

• A. Administer the medication by IV bolus over 2 minutes
• B. Infuse the medication slowly using an IV pump
• C. Add the medication to an IV solution of D5W
• D. Dilute the medication in 5 mL of sterile water

Correct answer: B

Rationale: The correct action to prevent complications when administering potassium chloride IV is to infuse the medication slowly using an IV pump. Rapid administration of potassium chloride can lead to complications such as hyperkalemia and cardiac arrest. Options A, C, and D are incorrect as they do not promote the safe administration of potassium chloride. Administering the medication by IV bolus over 2 minutes is too rapid and can cause adverse effects. Adding the medication to an IV solution of D5W or diluting it in sterile water may not control the rate of administration, increasing the risk of complications.

3. A nurse is preparing to administer morphine sulfate 2 mg IV bolus. Available is morphine sulfate 10 mg/mL. How many mL should the nurse administer per dose?

• A. 0.2 mL
• B. 0.4 mL
• C. 0.6 mL
• D. 0.8 mL

Correct answer: A

Rationale: The nurse should administer 0.2 mL of morphine sulfate. To calculate this, divide the desired dose (2 mg) by the concentration of the available solution (10 mg/mL). 2 mg / 10 mg/mL = 0.2 mL. Therefore, the nurse should administer 0.2 mL of morphine sulfate. Choices B, C, and D are incorrect as they do not reflect the accurate calculation based on the provided concentration and desired dose.

4. A 52-year-old client with a history of angina has been prescribed transdermal nitroglycerin. Which of the following adverse effects is not associated with this therapy?

• A. Tolerance
• B. Orthostatic hypotension
• C. Headache
• D. Productive cough

Correct answer: D

Rationale: The correct answer is D: Productive cough. Nitroglycerin therapy can lead to adverse effects such as tolerance, orthostatic hypotension, and headache. However, it is not known to cause a productive cough. Tolerance may develop over time, requiring dose adjustments. Orthostatic hypotension can occur due to vasodilation effects, leading to a sudden drop in blood pressure when changing positions. Headache is a common side effect due to vasodilation of cranial blood vessels. Productive cough is not a recognized adverse effect associated with transdermal nitroglycerin therapy.

5. A client is receiving magnesium sulfate for the management of preeclampsia. Which of the following client assessments should the nurse monitor to prevent complications of therapy?

• A. Bowel sounds
• B. Deep tendon reflexes
• C. Oxygen saturation
• D. Fluid balance

Correct answer: B

Rationale: The correct answer is deep tendon reflexes. Monitoring deep tendon reflexes is crucial to assess for magnesium toxicity during therapy for preeclampsia. Magnesium sulfate can lead to neuromuscular blockade, reflected by decreased or absent deep tendon reflexes. Assessing bowel sounds (choice A) is important for gastrointestinal function but is not directly related to magnesium sulfate therapy. Oxygen saturation (choice C) is vital for respiratory status but is not specifically linked to magnesium sulfate administration. Fluid balance (choice D) is essential but does not directly correlate with monitoring for complications of magnesium sulfate therapy in the context of preeclampsia.

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