Nursing Elites

1. A nurse is preparing to administer a dose of losartan. Which of the following should the nurse assess first?

• A. Blood pressure
• B. Heart rate
• C. Serum potassium
• D. Liver function

Correct answer: A

Rationale: The correct answer is to assess blood pressure first. Losartan is an angiotensin receptor blocker used to lower blood pressure. Assessing the patient's blood pressure before administering losartan is crucial to ensure it is not already too low, which could lead to hypotension. Assessing heart rate (choice B) is important but not the priority when administering losartan. Serum potassium levels (choice C) and liver function (choice D) are also important assessments, but they are not the primary concern before administering losartan.

2. A nurse is preparing to administer lactated Ringer's (LR) 1,000 mL IV to infuse over 8 hr. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?

• A. 19 gtt/min
• B. 20 gtt/min
• C. 21 gtt/min
• D. 22 gtt/min

Correct answer: C

Rationale: Calculation: 1000 mL / 480 minutes × 10 gtt/mL = 20.83, rounded to 21 gtt/min. This ensures proper IV fluid administration over the prescribed time. Choice C is the correct answer as it reflects the accurate calculation based on the given parameters. Choice A is incorrect because it does not accurately calculate the infusion rate. Choice B is incorrect as it does not consider the precise calculation required. Choice D is incorrect as it deviates from the correct calculation.

3. A client has a new prescription for metformin. Which of the following should the nurse educate the client about?

• A. It can cause weight gain
• B. It should be taken with meals
• C. It is an injectable medication
• D. It can cause hypoglycemia

Correct answer: B

Rationale: The correct answer is B: 'It should be taken with meals.' Metformin should be taken with meals to minimize gastrointestinal side effects and improve absorption. Choice A is incorrect because metformin is actually associated with weight loss or weight neutrality. Choice C is incorrect as metformin is typically taken orally and not via injection. Choice D is also incorrect because metformin is not known to cause hypoglycemia as a primary side effect.

4. A nurse is assessing a client with chronic kidney disease. Which of the following findings should the nurse monitor?

• A. Hypokalemia
• B. Fluid overload
• C. Decreased blood pressure
• D. Increased appetite

Correct answer: B

Rationale: The correct answer is B: Fluid overload. Clients with chronic kidney disease are prone to fluid overload due to impaired kidney function. The kidneys may not effectively regulate fluid balance, leading to fluid retention. Monitoring for signs of fluid overload, such as edema, hypertension, and shortness of breath, is crucial. Choice A, Hypokalemia, is less likely in chronic kidney disease as the kidneys often have difficulty excreting potassium, leading to hyperkalemia. Decreased blood pressure (Choice C) is not a common finding in chronic kidney disease unless complications like volume depletion occur. Increased appetite (Choice D) is not typically associated with chronic kidney disease; in fact, many clients may experience a decreased appetite due to various factors such as uremia and dietary restrictions.

5. A client is in the transition phase of labor. Which of the following actions should the nurse take?

• A. Assist the client to void every 3 hours
• B. Monitor contractions every 30 minutes
• C. Place the client in a lithotomy position
• D. Encourage the client to use a pant-blow breathing pattern

Correct answer: D

Rationale: Encouraging the client to use a pant-blow breathing pattern is crucial during the transition phase of labor. This phase is characterized by intense contractions and emotional responses. Pant-blow breathing helps manage pain and anxiety, providing comfort and support to the client. Voiding every 3 hours is not specific to the transition phase and may not address immediate needs. Monitoring contractions every 30 minutes is important but may not be as directly beneficial as focusing on coping mechanisms like breathing techniques. Placing the client in a lithotomy position is generally not recommended during the transition phase as it can impede progress and comfort.

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