Nursing Elites

1. A client returns from surgery with two Penrose drains in place. Anticipating frequent dressing changes, what should the nurse use around the incision site?

• A. Montgomery straps
• B. Sterile gauze
• C. Adhesive tape
• D. Elastic bandages

Correct answer: A

Rationale: Montgomery straps are the correct choice in this scenario. They are specifically designed to secure dressings around drain sites, like Penrose drains, and are ideal for frequent dressing changes. Sterile gauze (Choice B) is commonly used for wound dressings but may not provide the best securement for drains. Adhesive tape (Choice C) can cause skin irritation and may not be suitable for securing drains. Elastic bandages (Choice D) are typically used for compression or support but are not appropriate for securing dressings around drain sites.

2. A child weighing 20 kg has a new prescription for cefoxitin at 80 mg/kg/day administered intravenously every 6 hours. How much cefoxitin should be administered with each dose?

• A. 400 mg
• B. 200 mg
• C. 1600 mg
• D. 100 mg

Correct answer: A

Rationale: To determine the amount of cefoxitin to be administered with each dose, first, calculate the total daily dose by multiplying the child's weight (20 kg) by the prescribed dose (80 mg/kg/day): 80 mg/kg/day × 20 kg = 1600 mg/day. Since the medication is administered every 6 hours (4 doses/day), divide the total daily dose by the number of doses: 1600 mg / 4 = 400 mg. Therefore, each dose should be 400 mg. Choice B (200 mg) is incorrect because it is half the calculated dose. Choice C (1600 mg) is incorrect as it represents the total daily dose, not the dose per administration. Choice D (100 mg) is incorrect as it is a quarter of the calculated dose.

3. When using an open irrigation technique for a client's catheter, what action should the nurse take?

• A. Subtract the amount of irrigant used from the client's urine output.
• B. Add the amount of irrigant used to the urine output measurement.
• C. Measure the amount of irrigant used separately from the urine output.
• D. Document the total amount of fluid used for irrigation only.

Correct answer: A

Rationale: The correct action for the nurse to take when using an open irrigation technique for a client's catheter is to subtract the amount of irrigant used from the client's urine output. This subtraction helps accurately assess the client's output by accounting for the volume of irrigant introduced. Choice B is incorrect because adding the irrigant to the urine output measurement would falsely inflate the total output, leading to inaccurate assessment. Choice C is incorrect as measuring the amount of irrigant separately does not provide an accurate assessment of the client's total output as it disregards the irrigant's contribution. Choice D is incorrect as documenting the total fluid used for irrigation only does not differentiate between the irrigant and the client's actual urine output, which is crucial for accurate monitoring and assessment.

4. A client with a history of hypertension is prescribed a beta-blocker. Which side effect should the LPN/LVN monitor for in this client?

• A. Increased appetite
• B. Dry mouth
• C. Bradycardia
• D. Insomnia

Correct answer: C

Rationale: The correct side effect that the LPN/LVN should monitor for in a client prescribed a beta-blocker is bradycardia. Beta-blockers work by slowing down the heart rate, which can lead to bradycardia as a common side effect. Monitoring the client's heart rate is crucial, as bradycardia can be a serious condition. Choices A, B, and D are incorrect because increased appetite, dry mouth, and insomnia are not typically associated with beta-blockers. Increased appetite is more commonly linked to certain medications like corticosteroids, dry mouth can be a side effect of anticholinergic medications, and insomnia may be a side effect of stimulant medications.

5. The healthcare provider is caring for a client with tuberculosis (TB). Which type of isolation precautions should the healthcare provider implement?

• A. Droplet precautions
• B. Airborne precautions
• C. Contact precautions
• D. Standard precautions

Correct answer: B

Rationale: When caring for a client with tuberculosis (TB), airborne precautions should be implemented. Tuberculosis is spread through the air via droplet nuclei, requiring the use of airborne precautions to prevent the transmission of the infection. Droplet precautions are used for diseases spread by large respiratory droplets, such as influenza or pertussis. Contact precautions are used for diseases that spread through direct contact, such as MRSA. Standard precautions are used for all clients to prevent the transmission of infections from blood, body fluids, non-intact skin, and mucous membranes.

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