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. While assessing a client who is experiencing Cheyne-Stokes respirations, the nurse observes periods of apnea. What action should the nurse implement?

• A. Elevate the head of the client's bed
• B. Auscultate the client's breath sounds
• C. Measure the length of the apneic periods
• D. Suction the client's oropharynx

Correct answer: C

Rationale: When a nurse observes periods of apnea in a client experiencing Cheyne-Stokes respirations, measuring the length of the apneic periods is essential. This action helps in determining the severity of Cheyne-Stokes respirations by providing valuable information about the duration of interrupted breathing cycles. Elevating the head of the client's bed (Choice A) may be beneficial in some respiratory conditions but is not the priority in Cheyne-Stokes respirations. Auscultating the client's breath sounds (Choice B) is a general assessment and may not directly address the issue of apnea in Cheyne-Stokes respirations. Suctioning the client's oropharynx (Choice D) is not the initial intervention for managing Cheyne-Stokes respirations unless secretions are obstructing the airway.

3. Several clients on a telemetry unit are scheduled for discharge in the morning, but a telemetry-monitored bed is needed immediately. The charge nurse should make arrangements to transfer which client to another medical unit?

• A. Learning to self-administer insulin injections after being diagnosed with diabetes mellitus
• B. Ambulatory following coronary artery bypass graft surgery performed six days ago
• C. Wearing a sling immobilizer following permanent pacemaker insertion earlier that day
• D. Experiencing syncopal episodes resulting from the dehydration caused by severe diarrhea

Correct answer: A

Rationale: The correct answer is A because transferring a stable client who is learning self-care, such as self-administering insulin injections after being diagnosed with diabetes mellitus, provides the needed telemetry-monitored bed without compromising the client's care. Choice B should not be transferred as the client is ambulatory following surgery and does not require telemetry monitoring. Choice C should not be transferred as the client is wearing a sling immobilizer following pacemaker insertion, which requires close monitoring. Choice D should not be transferred as the client is experiencing syncopal episodes due to severe dehydration, necessitating telemetry monitoring for immediate intervention.

4. A client with diabetes mellitus reports feeling dizzy and has a blood glucose level of 50 mg/dl. What action should the nurse take first?

• A. Administer 1 mg of glucagon intramuscularly
• B. Provide 15 grams of carbohydrate
• C. Check the client's blood pressure
• D. Notify the healthcare provider

Correct answer: B

Rationale: Providing 15 grams of carbohydrate is the initial action to treat hypoglycemia. When a client with diabetes mellitus experiences symptoms of hypoglycemia, such as dizziness and with a blood glucose level of 50 mg/dl, the immediate priority is to raise their blood sugar levels quickly. Administering carbohydrates, such as fruit juice or glucose tablets, is the recommended first step to reverse hypoglycemia. Administering glucagon intramuscularly is usually reserved for severe hypoglycemia when the client is unconscious or unable to swallow. Checking the client's blood pressure is important but not the primary intervention for hypoglycemia. Notifying the healthcare provider can be done after the immediate management of hypoglycemia.

5. A client with diabetes mellitus reports feeling shaky and has a blood glucose level of 60 mg/dl. What action should the nurse take?

• A. Administer 15 grams of carbohydrate
• B. Administer a glucagon injection
• C. Provide a snack with protein
• D. Encourage the client to rest

Correct answer: A

Rationale: In the scenario described, the client is experiencing hypoglycemia with a blood glucose level of 60 mg/dl. The appropriate action for the nurse to take is to administer 15 grams of carbohydrate. Carbohydrate intake helps to rapidly raise blood sugar levels in cases of hypoglycemia. Administering a glucagon injection (Choice B) is not the initial treatment for mild hypoglycemia; it is typically used for severe hypoglycemia when the client is unable to consume oral carbohydrates. Providing a snack with protein (Choice C) is not the first-line intervention for hypoglycemia; immediate carbohydrate intake is necessary to raise blood sugar levels quickly. Encouraging the client to rest (Choice D) may be appropriate after administering the carbohydrate, but the priority is to address the low blood glucose levels by administering carbohydrates first.

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