Nursing Elites

1. Which of the following assessments is the most important for a patient receiving IV potassium?

• A. Respiratory rate
• B. Heart rate
• C. Blood pressure
• D. Oxygen saturation

Correct answer: C

Rationale: The most important assessment for a patient receiving IV potassium is monitoring blood pressure. IV potassium can cause significant changes in cardiac function, leading to adverse effects such as arrhythmias and cardiac arrest. While respiratory rate, heart rate, and oxygen saturation are important parameters to monitor in clinical practice, blood pressure takes precedence in patients receiving IV potassium due to its direct impact on cardiovascular function. Changes in blood pressure can be an early indicator of potassium-induced cardiac complications, making it crucial to monitor closely during administration.

2. A nursing assistant is measuring the blood pressure (BP) of a hypertensive client while a nurse observes. Which action on the part of the assistant would interfere with accurate measurement and prompt the nurse to intervene? Select all that apply.

• A. Measuring the BP after the client has sat quietly for 5 minutes
• B. Having the client sit with the arm bared and supported at heart level
• C. Using a cuff with a rubber bladder that encircles less than 80% of the limb
• D. Measuring the BP after the client reports that he just drank a cup of coffee

Correct answer: C

Rationale: To ensure accurate blood pressure (BP) measurement, the cuff used should have a rubber bladder that encircles at least 80% of the limb being measured. This ensures proper compression and accurate readings. Choices A and B are correct practices as it is recommended to measure BP after the client has sat quietly for 5 minutes and to have the client sit with the arm bared and supported at heart level. Choice D is also a correct reason for intervention as the client should not have consumed caffeine or smoked tobacco within 30 minutes before BP measurement, as it can affect the accuracy of the reading.

3. A client with acute kidney injury has a blood pressure of 76/55 mm Hg. The health care provider ordered 1000 mL of normal saline to be infused over 1 hour to maintain perfusion. The client is starting to develop shortness of breath. What is the nurse’s priority action?

• A. Calculate the mean arterial pressure (MAP).
• B. Ask for insertion of a pulmonary artery catheter.
• C. Take the client’s pulse.
• D. Slow down the normal saline infusion.

Correct answer: D

Rationale: The nurse should recognize that the client may be developing fluid overload and respiratory distress due to the rapid normal saline infusion. The priority action is to slow down the infusion to prevent worsening respiratory distress and potential fluid overload. While calculating the mean arterial pressure (MAP) is important to assess perfusion, addressing the immediate respiratory distress takes precedence. Inserting a pulmonary artery catheter would provide detailed hemodynamic information but is not the initial step in managing acute respiratory distress. Monitoring vital signs, including the client's pulse, is crucial after adjusting the intravenous infusion to ensure a safe response to the intervention.

4. The healthcare professional is reviewing a patient’s chart prior to administering gentamicin (Garamycin) and notes that the last serum peak drug level was 9 mcg/mL and the last trough level was 2 mcg/mL. What action will the healthcare professional take?

• A. Administer the next dose as prescribed.
• B. Obtain repeat peak and trough levels before administering the next dose.
• C. Report potential drug toxicity to the patient’s healthcare provider.
• D. Notify the patient’s healthcare provider of decreased drug therapeutic level.

Correct answer: C

Rationale: Gentamicin peak levels should ideally be between 5 to 8 mcg/mL, and trough levels should be within the range of 0.5 to 2 mcg/mL to ensure therapeutic efficacy while minimizing toxicity risk. In this case, the patient's peak level is above the recommended range, and the trough level is at the higher end, indicating potential drug toxicity. Therefore, the correct action for the healthcare professional is to report the possibility of drug toxicity to the patient’s healthcare provider. Administering the next dose as prescribed (Choice A) would exacerbate the toxicity risk. Obtaining repeat peak and trough levels (Choice B) may confirm the current levels but does not address the immediate concern of potential toxicity. Reporting a decreased drug therapeutic level (Choice D) is not the priority in this scenario, as the focus should be on addressing the potential toxicity issue.

5. An emergency department nurse assesses a client with a history of urinary incontinence who presents with extreme dry mouth, constipation, and an inability to void. Which question should the nurse ask first?

• A. Are you drinking plenty of water?
• B. What medications are you taking?
• C. Have you tried laxatives or enemas?
• D. Has this type of thing ever happened before?

Correct answer: B

Rationale: In this scenario, the client's symptoms of dry mouth, constipation, and inability to void are indicative of anticholinergic side effects, which can be caused by medications like propantheline (Pro-Banthine) commonly used to treat incontinence. The first question the nurse should ask is about the client's medications to determine if they are taking anticholinergic drugs. This information is crucial as it can help differentiate between a simple side effect or a potential overdose. Asking about water intake (Choice A) may be relevant later but is not the priority in this situation. Questioning about laxatives or enemas (Choice C) and past occurrences (Choice D) are not as pertinent initially as identifying the client's current medication status.

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