Nursing Elites

1. The healthcare professional prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The infusion set delivers 10 drops per milliliter. The healthcare professional should regulate the IV to administer approximately how many drops per minute?

• A. 80
• B. 8
• C. 21
• D. 25

Correct answer: C

Rationale: To calculate the drops per minute for the IV infusion, first determine the total drops to be infused over 8 hours. 1,000 ml to be infused over 8 hours means 125 ml per hour (1000 ml / 8 hours = 125 ml/hr). Since the infusion set delivers 10 drops per ml, 125 ml/hr x 10 drops/ml = 1250 drops/hr. To find drops per minute, divide the drops per hour by 60 (minutes in an hour): 1250 drops/hr / 60 minutes = 20.83 drops/minute, which rounds up to 21 drops per minute (Option C). This rate ensures the correct infusion rate over 8 hours. Choices A, B, and D are incorrect calculations and do not provide the appropriate infusion rate needed to administer the IV over the specified time period.

2. A client with a history of chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 liters per minute via nasal cannula. The client is short of breath and has a pulse oximetry reading of 88%. What action should the LPN take first?

• A. Increase the oxygen flow rate to 4 liters per minute.
• B. Reposition the client to a high Fowler's position.
• C. Notify the healthcare provider of the client's condition.
• D. Encourage the client to use pursed-lip breathing.

Correct answer: B

Rationale: Repositioning the client to a high Fowler's position should be the first action taken by the LPN. This position helps improve oxygenation by maximizing lung expansion, making it easier for the client to breathe. Increasing the oxygen flow rate without addressing positioning may not fully optimize oxygen delivery. Notifying the healthcare provider should come after immediate interventions. Encouraging pursed-lip breathing is beneficial but should follow the initial positioning to further assist the client in managing their breathing difficulty.

3. A client is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?

• A. Ask the client to consider a direct donation
• B. Withhold the blood transfusion
• C. Request a consultation with the ethics committee
• D. Ask the client's family to intervene

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to withhold the blood transfusion. The principle of autonomy ensures that a competent client has the right to refuse treatment, even if their decision conflicts with the wishes of their partner or family. Asking the client to consider a direct donation (Choice A) is not appropriate as it disregards the client's autonomy and religious beliefs. Requesting a consultation with the ethics committee (Choice C) may be considered in complex ethical dilemmas, but in this case, the client's autonomy should be respected first. Asking the client's family to intervene (Choice D) is not appropriate as the client has the right to make their own healthcare decisions based on their religious beliefs.

4. A client has extracellular fluid volume deficit. Which of the following findings should the nurse expect?

• A. Postural hypotension
• B. Distended neck veins
• C. Dependent edema
• D. Bradycardia

Correct answer: A

Rationale: Postural hypotension is a common sign of extracellular fluid volume deficit due to decreased blood volume, leading to a drop in blood pressure upon standing. Distended neck veins, dependent edema, and bradycardia are not typically associated with extracellular fluid volume deficit. Distended neck veins are more indicative of fluid volume overload, dependent edema is a sign of fluid retention, and bradycardia is not a common finding in extracellular fluid volume deficit.

5. A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor?

• A. Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back
• B. Pinch the skin on the back of the hand and observe for elasticity
• C. Assess the skin turgor on the abdomen by pinching the skin
• D. Check the skin turgor by pressing on the forearm and observing the rebound

Correct answer: A

Rationale: To assess skin turgor, the nurse should grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back. This method is preferred for older adults and in cases of significant fluid imbalance. Option B is incorrect as assessing skin turgor on the back of the hand is not the standard assessment site for skin turgor. Option C is incorrect as the abdomen is not the typical area for assessing skin turgor; the chest under the clavicle is a more accurate site. Option D is incorrect as pressing on the forearm is not the appropriate site for evaluating skin turgor; the chest under the clavicle is the recommended location for this assessment.

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