Nursing Elites

1. After successful resuscitation, a client is given propranolol and transferred to the Intensive Coronary Care Unit (ICCU). On admission, magnesium sulfate 4 grams IV in 250 ml D5W at one gram/hour. Which assessment findings require immediate intervention by the nurse?

• A. Dark amber urine draining via an indwelling catheter at a rate of 40 ml per hour
• B. Serum calcium of 9.0 mg/dl (2.2 mmol/L SI) and magnesium of 1.8 mg/dl or Eq/L (0.74 mmol/L SI)
• C. Sinus rhythm at 72 beats/minute and peripheral blood pressure of 99/62
• D. Respiratory rate of 10 breaths per minute

Correct answer: D

Rationale: The correct answer is D. A low respiratory rate of 10 breaths per minute is indicative of possible magnesium toxicity, which can be a serious condition requiring immediate intervention. It is a critical finding that needs prompt attention to prevent further complications. The other options are not as urgent: A - dark amber urine may indicate dehydration but does not require immediate intervention, B - serum calcium and magnesium levels are within normal limits, C - sinus rhythm and blood pressure values are also within normal range and do not require immediate action.

2. A male client with hypertension, who received new antihypertensive prescriptions at his last visit, returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106, and he admits that he has not been taking the prescribed medication because the drugs make him 'feel bad.' In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition?

• A. Feed the client a snack
• B. Empty the urinary drainage bag
• C. Offer the client oral fluids
• D. Stroke secondary to hemorrhage

Correct answer: D

Rationale: Elevated blood pressure, if left uncontrolled, significantly increases the risk of stroke secondary to hemorrhage and other cardiovascular events. This condition can lead to serious complications due to the increased pressure on the blood vessels in the brain. Choices A, B, and C are unrelated to the potential pathophysiological consequences of uncontrolled hypertension and are not the primary concern in this scenario.

3. The healthcare provider prescribes potassium chloride 25 mEq in 500 ml D5W to infuse over 6 hours. The available 20 ml vial of potassium chloride is labeled '10 mEq/5 ml.' How many ml of potassium chloride should the nurse add to the IV fluid?

• A. 12.5
• B. 5
• C. 10
• D. 20

Correct answer: B

Rationale: To prepare 25 mEq of potassium chloride for the infusion, the nurse should add 5 ml of the 10 mEq/5 ml solution. This concentration provides the required amount of potassium chloride without exceeding the needed volume. Choice A would result in 12.5 mEq, which exceeds the prescribed amount. Choices C and D are incorrect as they do not align with the correct calculation based on the vial concentration.

4. The nurse is preparing to administer an IM dose of vitamin B1 (Thiamine) to a male client experiencing acute alcohol withdrawal and peripheral neuritis. The client belligerently states, “What do you think you’re doing?” How should the nurse respond?

• A. “I cannot give you this medication until you calm down.”
• B. “This shot will help relieve the pain in your feet.”
• C. “Would you prefer to learn to administer your own shot?”
• D. “You will feel calmer and less jittery after this shot.”

Correct answer: B

Rationale: The correct response is to provide a relevant explanation to the client. Choice B, “This shot will help relieve the pain in your feet,” is the best answer because it directly addresses the client's concern about the purpose of the medication. By explaining the potential benefit of the injection, the nurse can alleviate the client's anxiety and increase their cooperation during the procedure. Choice A is incorrect as it dismisses the client's question and may escalate the situation. Choice C is not suitable as it deviates from addressing the client's immediate query. Choice D is incorrect because it fails to specifically address the client's concern regarding the medication's purpose.

5. A 2-year-old boy with short bowel syndrome has progressed to receiving enteral feedings only. Today his stools are occurring more frequently and have a more liquid consistency. His temperature is 102.2 °F, and he has vomited twice in the past four hours. Which assessment finding indicates that the child is becoming dehydrated?

• A. Occult blood in the stool
• B. Abdominal distention
• C. Elevated urine specific gravity
• D. Hyperactive bowel sounds

Correct answer: C

Rationale: Elevated urine specific gravity indicates concentrated urine, a sign of dehydration. In this scenario, the child is showing signs of dehydration with increased stool frequency, liquid consistency, fever, and vomiting. Occult blood in the stool may indicate gastrointestinal bleeding but is not a specific sign of dehydration. Abdominal distention can be seen in various conditions and is not a specific indicator of dehydration. Hyperactive bowel sounds can be present in various gastrointestinal conditions but are not directly related to dehydration.

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