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Questions 149

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Question 1 of 5

The physician has ordered 50 mEq of potassium chloride for a client with a potassium level of 2.5 mEq. The nurse should administer the medication:

Correct Answer: C

Rationale: Potassium chloride should be administered slowly (e.g., over 5 hours for 50 mEq) to prevent cardiac complications, as rapid infusion can cause hyperkalemia.

Question 2 of 5

A pregnant client is keeping a 'kick count' log during the last trimester. Which of the following may indicate fetal distress?

Correct Answer: C

Rationale: Fewer than 10 movements in 2 hours (
C) suggests fetal distress, as normal is >10 movements in 2 hours. Other options (A, B,
D) set incorrect thresholds.

Question 3 of 5

The nurse is working with an unlicensed assistive personnel (UAP). In planning the morning's care, which tasks can the nurse delegate to the UAP? Select all that apply.

Correct Answer: A, C

Rationale: Feeding and assisting a stable client to the commode are within the UAP’s scope, while starting an IV, checking an apical pulse, and ambulating a post-surgical client require nursing judgment.

Question 4 of 5

Which of the following medication orders requires clarification before the nurse can administer the order?

Correct Answer: B

Rationale: Heparin dosing (30 units/kg/hr) is unusually low for anticoagulation (typically 10-20 units/kg/hr). This requires clarification to ensure safety.

Question 5 of 5

The nurse is caring for a client following a crushing injury to the chest. Which finding would be most indicative of a tension pneumothorax?

Correct Answer: B

Rationale: Tension pneumothorax causes a mediastinal shift, including tracheal deviation toward the unaffected side due to increased intrathoracic pressure.

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