Nursing Elites

1. What is the rate of delivery in mL/hr if a total volume of 750 mL is infused over a period of 7 hours?

• A. 107 mL/hr.
• B. 107 mL/hr.
• C. 107 mL/hr.
• D. 107 mL/hr.

Correct answer: A

Rationale: The correct rate of delivery is 107 mL/hr. To find the rate of delivery, divide the total volume by the total time: 750 mL / 7 hours = 107 mL/hr. Choice B, C, and D are incorrect as they do not match the correct calculation based on the total volume and time provided.

2. A client with a history of heart failure presents to the clinic with a 2-day history of weight gain, swelling in the legs, and shortness of breath. Which of the following is the most appropriate initial nursing action?

• A. Perform a physical assessment
• B. Review the client's medication list
• C. Instruct the client to elevate the legs
• D. Obtain a detailed dietary history

Correct answer: A

Rationale: Performing a physical assessment is the most appropriate initial nursing action in this scenario. A thorough physical assessment helps evaluate the client's current condition, severity of symptoms, and identify any immediate concerns. This assessment can provide crucial information to guide further interventions and treatment. Reviewing the client's medication list (choice B) is important but may not address the immediate need for assessing the client's current status. Instructing the client to elevate the legs (choice C) may be beneficial but should come after a thorough assessment. Obtaining a detailed dietary history (choice D) is relevant for heart failure management but is not the most urgent initial action when the client presents with acute symptoms like weight gain, leg swelling, and shortness of breath.

3. A client has a new cast on the left arm, and the nurse is assessing the client. Which of the following findings should the nurse report to the provider immediately?

• A. Increased warmth in the affected arm
• B. Itching under the cast
• C. Pain with passive movement
• D. Drainage on the cast

Correct answer: C

Rationale: The correct answer is C: Pain with passive movement. Pain with passive movement in a client with a new cast can indicate compartment syndrome, a serious condition where pressure builds up within the muscles, nerves, and blood vessels of the affected limb, potentially leading to tissue damage. Immediate reporting is crucial to prevent further complications. Increased warmth in the affected arm could be a normal inflammatory response to the injury and casting process. Itching under the cast is common and can be managed without immediate concern. Drainage on the cast may be expected initially after casting due to residual moisture from the setting process, but ongoing or excessive drainage should be monitored and reported if persistent.

4. During a physical assessment on a toddler, what should be the first action?

• A. Perform traumatic procedures
• B. Use minimal physical contact
• C. Proceed from head to toe
• D. Explain the exam in detail

Correct answer: B

Rationale: The correct first action when performing a physical assessment on a toddler is to use minimal physical contact. This approach helps the toddler become comfortable and reduces anxiety during the assessment. Traumatic procedures (Choice A) should never be the first action as they can cause distress. Proceeding from head to toe (Choice C) is a common sequence in physical assessments but does not address the initial need to establish trust and comfort. Explaining the exam in detail (Choice D) is important but should come after establishing a rapport through minimal physical contact.

5. A client who is unstable and requires frequent vital signs has an electronic blood pressure machine automatically measuring his blood pressure every 15 min. However, the machine is reading the client’s blood pressure at more frequent intervals, and the readings are not similar. The nurse checks the machine settings and observes the additional readings, but the problem continues. Which of the following is the appropriate nursing action?

• A. Notify the manufacturer
• B. Disconnect the machine, and measure the blood pressure manually every 15 min
• C. Adjust the machine settings again
• D. Ignore the extra readings

Correct answer: B

Rationale: The correct action in this scenario is to disconnect the electronic blood pressure machine and measure the client's blood pressure manually every 15 minutes. Given that the machine is malfunctioning and providing inconsistent readings, relying on manual measurements ensures accuracy and maintains the quality of care. Notifying the manufacturer (Choice A) may be necessary in the long run, but the immediate concern is the accuracy of the vital signs. Adjusting the machine settings again (Choice C) without resolving the underlying issue would not address the problem. Ignoring the extra readings (Choice D) could lead to incorrect assessment and compromise patient care. Therefore, the best course of action is to disconnect the machine and opt for manual blood pressure measurements until the issue is resolved.

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