Nursing Elites

1. A client who is bleeding after a vaginal delivery receives a prescription for methylergonovine (Methergine) 0.4 mg IM every 2 hours, not to exceed 5 doses. The medication is available in ampules containing 0.2 mg/ml. What is the maximum dosage in mg that the nurse should administer to this client?

• A. Encourage oral fluids as tolerated
• B. Decrease oral intake to 200 ml
• C. Allow the client to have exactly 400 ml oral intake
• D. Limit oral intake to 900 to 1,000 ml

Correct answer: D

Rationale: The maximum dosage the nurse should administer is 2 mg. This is calculated based on the prescription of 0.4 mg IM every 2 hours, not to exceed 5 doses. Since the medication is available in ampules containing 0.2 mg/ml, the nurse should administer 2 ml (0.2 mg/ml x 10 ml) for each dose, not exceeding 5 doses. Therefore, the nurse should limit the client's oral intake to 900 to 1,000 ml, to avoid exceeding the maximum dosage of 2 mg.

2. A client with a history of heart failure is admitted to the hospital with worsening dyspnea. The nurse notes that the client has a productive cough with pink, frothy sputum. What action should the nurse take first?

• A. Administer oxygen
• B. Perform chest physiotherapy
• C. Elevate the head of the bed
• D. Obtain a sputum specimen

Correct answer: A

Rationale: In a client with heart failure presenting with worsening dyspnea and pink, frothy sputum (indicating pulmonary edema), the priority action for the nurse is to administer oxygen. Oxygen therapy helps improve oxygenation and alleviate dyspnea by increasing the oxygen supply to the lungs. Performing chest physiotherapy, elevating the head of the bed, or obtaining a sputum specimen are not the initial actions indicated in this situation and may delay addressing the client's immediate need for improved oxygenation.

3. A 3-year-old boy is brought to the emergency center with dysphagia, drooling, a fever of 102°F, and stridor. Which intervention should the nurse implement first?

• A. Place the child in a mist tent
• B. Obtain a sputum culture
• C. Prepare for an emergent tracheostomy
• D. Examine the child's oropharynx and report the findings to the healthcare provider

Correct answer: A

Rationale: In a 3-year-old boy presenting with dysphagia, drooling, fever, and stridor, the priority intervention should be to place the child in a mist tent. This intervention helps alleviate respiratory distress, providing immediate relief. Options B, C, and D are not as urgent as ensuring the child's airway is managed effectively. Obtaining a sputum culture, preparing for a tracheostomy, and examining the oropharynx can be done after stabilizing the child's respiratory status.

4. A client who is 12-hours post-op following a left hip replacement has an indwelling urinary catheter. The nurse determines that the client's urinary output is 60 ml in the past 3 hours. What action should the nurse take first?

• A. Assess the client's vital signs
• B. Irrigate the catheter with 30 ml of sterile normal saline
• C. Notify the healthcare provider
• D. Replace the catheter with a larger size

Correct answer: A

Rationale: In a client post-op with low urinary output, the first action the nurse should take is to assess the client's vital signs. Vital signs can provide valuable information about the client's overall condition, fluid status, and potential complications. Assessing the vital signs can help the nurse to determine if the low urine output is indicative of a larger issue that needs immediate attention. Irrigating the catheter with normal saline may be necessary but should not be the first action without assessing the client. Notifying the healthcare provider should follow assessment if there are concerns. Replacing the catheter with a larger size is not indicated solely based on low urinary output and should not be the first action taken.

5. A client who is HIV positive and taking lamivudine (Epivir) calls the clinic to report a cough and fever. What action should the nurse implement?

• A. Advise the client to come to the clinic for an evaluation
• B. Advise the client to increase fluid intake
• C. Advise the client to take an over-the-counter cough suppressant
• D. Advise the client to rest and call if the fever persists

Correct answer: A

Rationale: The correct action for the nurse to implement in this situation is to advise the client to come to the clinic for an evaluation. Given the client's HIV-positive status and medication, it is crucial to assess the cough and fever promptly to identify the underlying cause. Increasing fluid intake (choice B) may be beneficial but does not address the need for evaluation. Taking an over-the-counter cough suppressant (choice C) may not be appropriate without knowing the cause of the symptoms. Advising the client to rest and call if the fever persists (choice D) delays the necessary evaluation and treatment.

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