Nursing Elites

1. Before administration of a stat dose of potassium chloride IV for a client with hypokalemia, what is the most important action for the nurse?

• A. Ensure the IV is flowing freely
• B. Mix the medication thoroughly
• C. Check the client’s electrolyte levels
• D. Obtain a baseline ECG

Correct answer: A

Rationale: The most crucial action for the nurse before administering a stat dose of potassium chloride IV to a client with hypokalemia is to ensure the IV is flowing freely. A freely flowing IV is essential to safely and effectively deliver potassium chloride, helping to prevent infusion-related issues. Checking the client's electrolyte levels or obtaining a baseline ECG may be important but are not the most critical actions before administering the medication. Mixing the medication thoroughly is not applicable in this scenario as potassium chloride is typically provided ready to use.

2. Prior to administering morphine sulfate (Morphine), the nurse takes the client's vital signs. Based on which finding should the nurse withhold administration of the medication until the charge nurse is notified?

• A. Temperature of 100.8°F
• B. A pulse rate of 150 beats per minute
• C. A respiratory rate of 10 breaths per minute
• D. A blood pressure of 180/110

Correct answer: C

Rationale: The correct answer is C because a low respiratory rate is a critical concern when administering opioids like morphine, as they can suppress breathing. A high pulse rate (choice B) and high blood pressure (choice D) are not immediate contraindications for administering morphine. A slightly elevated temperature (choice A) may not necessarily require withholding morphine.

3. During a severe asthma exacerbation in a client, what is the nurse's priority?

• A. Administer a rescue inhaler immediately
• B. Prepare for intubation
• C. Encourage deep breathing exercises
• D. Monitor oxygen saturation levels

Correct answer: A

Rationale: During a severe asthma exacerbation, the nurse's priority is to administer a rescue inhaler immediately. This action helps open the airways and improve breathing, which is crucial in managing the exacerbation. Choice B, preparing for intubation, would be considered if the client's condition deteriorates and they are unable to maintain adequate oxygenation even after using the rescue inhaler. Encouraging deep breathing exercises (Choice C) may not be appropriate during a severe exacerbation as the client may struggle to breathe. While monitoring oxygen saturation levels (Choice D) is important, the immediate administration of a rescue inhaler takes precedence to address the acute breathing difficulty.

4. Which of the following are key parameters that produce blood pressure? (Select ONE that does not apply)

• A. Heart rate
• B. Stroke volume
• C. Peripheral resistance
• D. Neuroendocrine hormones

Correct answer: D

Rationale: Heart rate, stroke volume, and peripheral resistance are indeed key parameters that directly influence blood pressure. Heart rate refers to the number of times the heart beats per minute, affecting how much blood is pumped. Stroke volume is the amount of blood pumped by the heart in one contraction. Peripheral resistance is the resistance of the arteries to blood flow, impacting the pressure needed to push blood through. Neuroendocrine hormones, while they can indirectly influence blood pressure regulation by affecting factors like blood volume and vascular tone, are not direct final parameters that produce blood pressure.

5. When counting a client's radial pulse, the nurse notes the pulse is weak and irregular. To record the most accurate heart rate, what should the nurse do?

• A. Recheck the radial pulse in thirty minutes
• B. Palpate the radial pulse for thirty seconds and double the rate
• C. Count the apical pulse rate for sixty seconds
• D. Compare the radial pulse rate bilaterally and record the higher rate

Correct answer: C

Rationale: The correct answer is to count the apical pulse rate for sixty seconds. The apical pulse is more accurate, especially when peripheral pulses are weak or irregular. Counting the apical pulse for a full minute provides a more precise heart rate measurement. Option A is incorrect because waiting for thirty minutes is unnecessary and could delay potential interventions. Option B is incorrect because doubling the radial pulse rate may not provide an accurate representation of the heart rate. Option D is incorrect because comparing radial pulses bilaterally does not give the most accurate heart rate measurement; the apical pulse is preferred in this situation.

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