Nursing Elites

1. A 9-year-old is receiving vancomycin 400 mg IV every 6 hours for a methicillin-resistant (Beta-lactam-resistant) Staphylococci aureus (MRSA) infection. The medication is diluted in a 100 mL bag of saline with instructions to infuse over one and a half hours. How many mL/hour should the nurse program the infusion pump?

• A. 50
• B. 67
• C. 57
• D. 70

Correct answer: B

Rationale: To calculate the infusion rate for vancomycin, you need to divide the total volume by the total time of infusion. In this case, the total volume is 100 mL, and the total time is 1.5 hours. Therefore, 100 mL ÷ 1.5 hours = 67 mL/hour. This means the nurse should program the infusion pump to deliver vancomycin at a rate of 67 mL/hour. Choice A (50) is incorrect as it does not reflect the correct calculation. Choice C (57) is incorrect as it is not the accurate calculation based on the provided information. Choice D (70) is incorrect as it does not correspond to the correct infusion rate calculation.

2. The nurse is caring for a client who is scheduled for surgery in the morning. The client reports drinking a glass of water at midnight. What should the nurse do?

• A. Notify the anesthesiologist
• B. Document the intake in the medical record
• C. Cancel the surgery
• D. Instruct the client to fast until the surgery

Correct answer: A

Rationale: The correct answer is to notify the anesthesiologist. When a client reports drinking water close to the time of surgery, it is important to inform the anesthesiologist as it can impact the administration of anesthesia. The anesthesiologist needs this information to make decisions regarding anesthesia administration. Documenting the intake in the medical record is important for documentation purposes, but the immediate action needed is to inform the anesthesiologist. Canceling the surgery is not necessary based solely on the intake of water; the anesthesiologist will determine the appropriate course of action. Instructing the client to fast until the surgery may not be appropriate without consulting the anesthesiologist first, as the situation needs to be assessed by the anesthesia team.

3. A client is scheduled for an abdominal ultrasound in the morning and has been instructed to fast overnight. The client asks the nurse why fasting is necessary. What is the best response?

• A. It helps reduce the production of intestinal gases.
• B. It ensures clearer imaging by emptying the stomach.
• C. It prevents the risk of aspiration during the procedure.
• D. It is a standard procedure for all surgical interventions.

Correct answer: B

Rationale: The correct answer is B: 'It ensures clearer imaging by emptying the stomach.' Fasting before an abdominal ultrasound is essential to empty the stomach, allowing for better visualization of the abdominal organs. This improves the quality of the imaging and enhances diagnostic accuracy. Choices A, C, and D are incorrect because reducing intestinal gases, preventing aspiration, and being a standard procedure for surgical interventions are not the primary reasons for fasting before an abdominal ultrasound.

4. A client with a diagnosis of myocardial infarction (MI) is prescribed nitroglycerin. What is the primary action of this medication?

• A. Increases heart rate
• B. Lowers blood pressure
• C. Dilates coronary arteries
• D. Reduces myocardial oxygen demand

Correct answer: C

Rationale: The correct answer is C: Nitroglycerin dilates coronary arteries, improving blood flow to the heart muscle. This helps increase oxygen supply to the heart tissue. Option A, 'Increases heart rate,' is incorrect because nitroglycerin does not directly affect heart rate. Option B, 'Lowers blood pressure,' is also incorrect as while nitroglycerin can lower blood pressure, its primary action in the context of MI is related to coronary artery dilation. Option D, 'Reduces myocardial oxygen demand,' is not the primary action of nitroglycerin in the treatment of myocardial infarction; its main action is to increase oxygen supply by dilating coronary arteries.

5. A client is being treated for dehydration. Which clinical finding would indicate that treatment is effective?

• A. Dry mucous membranes
• B. Increased urine output
• C. Tachycardia
• D. Hypotension

Correct answer: B

Rationale: The correct answer is B: Increased urine output. When a client is being treated for dehydration, increased urine output is a positive indication that the treatment is effective. This signifies that the body is beginning to rehydrate and eliminate excess fluid. Choices A, C, and D are incorrect because dry mucous membranes, tachycardia, and hypotension are all associated with dehydration and would not be signs of effective treatment.

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