Nursing Elites

1. A healthcare professional is preparing to administer 0.9% sodium chloride (0.9% NaCl) 250 mL IV to infuse over 30 min. The drop factor of the manual IV tubing is 10 gtt/mL. How many gtt/min should the healthcare professional adjust the manual IV infusion to deliver? (Round the answer to the nearest whole number. Do not use a trailing zero.)

• A. 83 gtt/min
• B. 125 gtt/min
• C. 100 gtt/min
• D. 75 gtt/min

Correct answer: C

Rationale: To administer 250 mL over 30 min with a drop factor of 10 gtt/mL, the healthcare professional should adjust the IV infusion to deliver 100 gtt/min. The correct calculation is: (250 mL ÷ 30 min) x 10 gtt/mL = 100 gtt/min. This rate ensures the proper administration of the IV solution within the specified time frame. Choices A, B, and D are incorrect as they do not align with the accurate calculation based on the provided data.

2. When caring for a client receiving warfarin sodium (Coumadin), which lab test would the nurse monitor to determine therapeutic response to the drug?

• A. Bleeding time
• B. Coagulation time
• C. Prothrombin time
• D. Partial thromboplastin time

Correct answer: C

Rationale: The correct answer is C: Prothrombin time (PT). Prothrombin time is monitored to assess the therapeutic response to warfarin therapy. Warfarin works by inhibiting vitamin K-dependent clotting factors, which prolongs the PT. Monitoring PT helps determine if the client's blood is clotting within the desired therapeutic range. Choices A, B, and D are incorrect because bleeding time, coagulation time, and partial thromboplastin time are not specifically used to monitor the therapeutic response to warfarin. Bleeding time assesses platelet function, coagulation time is a general term and not a specific test, and partial thromboplastin time is more relevant in monitoring heparin therapy, not warfarin.

3. A caregiver is talking with the caregivers of a 10-year-old child who is concerned that their child is becoming secretive, including closing the door when showering and dressing. Which of the following responses should the caregiver make?

• A. “Perhaps you should try to find out what is happening behind those closed doors.”
• B. “Suggest that the door be left ajar for safety reasons.”
• C. “At this age, children tend to become modest and value their privacy.”
• D. “You should establish a disciplinary plan to stop this behavior.”

Correct answer: C

Rationale: The correct response is C: “At this age, children tend to become modest and value their privacy.” During the developmental stage around 10 years old, children often start to value their privacy more and exhibit behaviors like closing doors when showering or dressing. It is a normal part of growing up and developing a sense of modesty. Choice A is incorrect as it suggests prying into the child's privacy, which may be counterproductive and invasive. Choice B is not the best response as it focuses on safety but fails to address the child's developmental stage and need for privacy. Choice D is also incorrect as it advocates for discipline without recognizing the normal developmental behavior of children at this age.

4. A client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take?

• A. Check the catheter to see whether it is patent.
• B. Reassure the client that it is not possible for them to urinate.
• C. Re-catheterize the bladder with a larger-gauge catheter.
• D. Collect a urine specimen for analysis.

Correct answer: A

Rationale: When a client with an indwelling catheter reports a need to urinate, the nurse's initial action should be to check the catheter for patency. This is crucial to ensure that the catheter is not blocked, twisted, or kinked, which could lead to urinary retention. Reassuring the client without assessing the catheter could delay necessary interventions. Re-catheterizing the bladder with a larger-gauge catheter should not be the first step unless catheter patency is confirmed as an issue. Collecting a urine specimen for analysis is important but not the immediate priority when the client reports a need to urinate.

5. When assessing a male client, the nurse finds that he is fatigued and is experiencing muscle weakness, leg cramps, and cardiac dysrhythmias. Based on these findings, the nurse plans to check the client's laboratory values to validate the existence of which condition?

• A. Hyperphosphatemia
• B. Hypocalcemia
• C. Hypermagnesemia
• D. Hypokalemia

Correct answer: D

Rationale: The symptoms of muscle weakness, leg cramps, and cardiac dysrhythmias are indicative of hypokalemia, a condition characterized by low potassium levels. Checking the client's laboratory values for potassium will help confirm this diagnosis. Hyperphosphatemia (Choice A) is an elevated phosphate level in the blood, which is not consistent with the symptoms described. Hypocalcemia (Choice B) is a low calcium level and typically presents with different symptoms than those mentioned in the scenario. Hypermagnesemia (Choice C) is an excess of magnesium in the blood and does not align with the symptoms of muscle weakness, leg cramps, and cardiac dysrhythmias observed in the client.

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