Nursing Elites

1. A nurse is caring for a client who has a prescription for metoprolol. For which of the following findings should the nurse withhold the medication?

• A. Heart rate 56/min.
• B. Oxygen saturation 93%.
• C. Respiratory rate 18/min.
• D. Blood pressure 118/74 mm Hg.

Correct answer: A

Rationale: The correct answer is A: Heart rate 56/min. Metoprolol, a beta blocker, should be withheld if the client's heart rate is below 60/min to prevent further bradycardia. Choices B, C, and D are within normal ranges and do not indicate a need to withhold metoprolol.

2. A nurse is caring for a client with dementia who is at risk of falls. What is the most appropriate intervention?

• A. Use a bed exit alarm to notify staff of attempts to leave the bed
• B. Raise all four side rails for safety
• C. Encourage frequent ambulation with assistance
• D. Use restraints to prevent the client from getting out of bed

Correct answer: A

Rationale: The most appropriate intervention for a client with dementia at risk of falls is to use a bed exit alarm to notify staff of attempts to leave the bed. This intervention allows for timely assistance and prevents falls. Raising all four side rails (Choice B) can lead to entrapment or agitate the client. Encouraging frequent ambulation with assistance (Choice C) may not be suitable for a client at high risk of falls. Using restraints (Choice D) should be avoided as they can increase agitation, risk of injury, and have ethical implications.

3. What are the key interventions in managing a patient with diabetic ketoacidosis (DKA)?

• A. Administer insulin and fluids
• B. Administer oral hypoglycemics
• C. Administer glucagon
• D. Administer insulin and monitor blood glucose

Correct answer: A

Rationale: The correct intervention in managing a patient with diabetic ketoacidosis (DKA) is to administer insulin and fluids. Insulin is crucial to correct hyperglycemia, while fluids are important to address dehydration. Administering oral hypoglycemics (Choice B) is not appropriate in the management of DKA as the patient may not be able to absorb oral medications due to gastrointestinal issues. Glucagon (Choice C) is not indicated in the treatment of DKA. Although monitoring blood glucose (Choice D) is important, it is not the sole key intervention for managing DKA; administering insulin and fluids are the primary interventions.

4. Which intervention is essential when caring for a client with heart failure on fluid restriction?

• A. Encourage the client to drink water throughout the day
• B. Monitor the client's weight daily to assess fluid balance
• C. Limit fluid intake during meals
• D. Weigh the client once a week to assess fluid balance

Correct answer: B

Rationale: The correct answer is B: 'Monitor the client's weight daily to assess fluid balance.' When caring for a client with heart failure on fluid restriction, it is essential to monitor their weight daily to evaluate fluid balance accurately. This helps healthcare providers assess if the client is retaining excess fluid, a common issue in heart failure. Choices A, C, and D are incorrect. Encouraging the client to drink water throughout the day contradicts fluid restriction. Limiting fluid intake during meals may not provide a comprehensive assessment of fluid balance, and weighing the client once a week is not frequent enough to detect rapid changes in fluid status that could worsen heart failure symptoms.

5. A client has developed phlebitis at the IV site. What is the next step the nurse should take?

• A. Administer an anti-inflammatory medication
• B. Discontinue the IV and notify the provider
• C. Apply a cold compress over the IV site
• D. Increase the IV flow rate to prevent dehydration

Correct answer: B

Rationale: When a client develops phlebitis at the IV site, the nurse's immediate action should be to discontinue the IV and notify the healthcare provider. Phlebitis is inflammation of the vein, and leaving the IV in place can lead to complications such as infection or thrombosis. Administering an anti-inflammatory medication (choice A) may not address the root cause and delay the necessary intervention. Applying a cold compress (choice C) may provide temporary relief but does not address the need to remove the source of inflammation. Increasing the IV flow rate (choice D) is contraindicated as it can exacerbate the phlebitis by causing more irritation to the vein.

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