Nursing Elites

1. The nurse is preparing to administer 10 mL of liquid potassium chloride through a feeding tube, followed by 10 mL of liquid acetaminophen. Which action should the nurse include in this procedure?

• A. Dilute each of the medications with sterile water prior to administration.
• B. Mix the medications in one syringe before opening the feeding tube.
• C. Administer water between the doses of the two liquid medications.
• D. Withdraw any fluid from the tube before instilling each medication.

Correct answer: C

Rationale: Water should be instilled into the feeding tube between administering the two medications to maintain the patency of the feeding tube and ensure that the total dose of medication enters the stomach and does not remain in the tube. These liquid medications do not need to be diluted when administered via a feeding tube. Mixing the medications in one syringe can lead to interactions or alterations in the medications' properties. Withdrawing any fluid from the tube before instilling each medication can cause inaccurate dosing and incomplete administration. Therefore, the correct action is to administer water between the doses of the two liquid medications to ensure proper delivery and avoid any complications.

2. The nurse selects the best site for insertion of an IV catheter in the client's right arm. Which documentation should the nurse use to identify the placement of the IV access?

• A. Left brachial vein
• B. Right cephalic vein
• C. Dorsal side of the right wrist
• D. Right upper extremity

Correct answer: B

Rationale: The correct answer is the right cephalic vein. The cephalic vein is a large and superficial vein commonly used for IV access. Documenting the specific anatomic name of the vein used for IV access, such as the cephalic vein, is essential for accurate medical records. Option A, the left brachial vein, is incorrect as the brachial vein is too deep to be accessed for IV infusion. Option C, the dorsal side of the right wrist, is not a recommended IV access site due to fragile veins and potential pain for the patient. Option D, right upper extremity, is too broad and lacks the specificity necessary for precise documentation of the IV access site.

3. A health care provider discusses with a client the need for an abdominoperineal resection and a colostomy. After the health care provider leaves the room, the client tells the nurse about being relieved that only minor surgery is necessary. Which psychological process explains this client's reaction?

• A. Reflection
• B. Regression
• C. Repudiation
• D. Reconciliation

Correct answer: C

Rationale: The client's reaction of believing that only minor surgery is necessary when faced with the need for an abdominoperineal resection and a colostomy is an example of repudiation. Repudiation involves a refusal to acknowledge anticipated loss as a defense mechanism against the overwhelming stress of illness. The client is psychologically denying the seriousness of the situation. The other choices are incorrect because: - Reflection (Choice A) does not apply since the client is not contemplating the issues of the situation. - Regression (Choice B) is not demonstrated as the client's behavior does not indicate reverting to an earlier stage of development. - Reconciliation (Choice D) is not applicable as the client has not made a realistic adjustment to the illness but rather is in denial of its severity.

4. Which feeling would be difficult for a client with major depression to express?

• A. Need for comforting
• B. Anger toward others
• C. Remorse for past behaviors
• D. Feelings of low self-esteem

Correct answer: B

Rationale: Clients with major depression often have difficulty expressing anger toward others as their anger is typically directed inwards. Expressing the need for comforting is common among clients with major depression. They can also articulate remorse for past behaviors to an excessive degree. Furthermore, feelings of low self-esteem can be openly expressed by clients with major depression. Therefore, the difficulty in expressing anger toward others is the most appropriate choice as clients with major depression tend to internalize their anger.

5. What step should be taken when administering ear drops to an adult client?

• A. Place the client in a side-lying position.
• B. Hold the dropper 1 cm above the ear canal.
• C. Place a cotton ball into the outermost canal.
• D. Pull the auricle down and back.

Correct answer: A

Rationale: The correct step when administering ear drops to an adult client is to place the client in a side-lying position (A). This position allows for easier administration of the drops and helps prevent spillage. The dropper should be held approximately 1 cm (� inch) above the ear canal (B) to ensure accurate delivery of the medication. Placing a cotton ball into the outermost canal (C) is unnecessary and may interfere with the absorption of the ear drops. Pulling the auricle down and back (D) is a technique used for children younger than 3 years old to straighten the ear canal, but it is not necessary for adults and may cause discomfort.

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