Nursing Elites

1. In what sequence should the nurse prepare the dose of insulin for a client whose finger stick glucose is 210 mg/dl and is receiving a sliding scale dose of short-acting insulin before breakfast?

• A. Clean the vial's rubber stopper with an alcohol swab, withdraw the correct dose of insulin, and then inject air equal to the insulin dose into the vial.
• B. Inject air equal to the insulin dose into the vial, withdraw the correct dose of insulin, and then clean the vial's rubber stopper with an alcohol swab.
• C. Withdraw the correct dose of insulin, inject air equal to the insulin dose into the vial, and then clean the vial's rubber stopper with an alcohol swab.
• D. Clean the vial's rubber stopper with an alcohol swab, inject air equal to the insulin dose into the vial, and then withdraw the correct dose of insulin.

Correct answer: A

Rationale: The correct sequence for preparing a dose of insulin involves ensuring proper aseptic technique. First, clean the vial's rubber stopper with an alcohol swab to prevent contamination. Second, withdraw the correct dose of insulin to be administered. Lastly, inject air equal to the insulin dose into the vial to maintain proper pressure for withdrawing the medication. This sequence ensures the medication is prepared safely and accurately. Choice A is correct as it follows this sequence. Choices B, C, and D present incorrect sequences that may compromise patient safety by not following the correct aseptic technique. Choice B injects air into the vial before withdrawing insulin, which is incorrect. Choice C reverses the order of withdrawing insulin and injecting air. Choice D withdraws the insulin before injecting air, which can affect the pressure inside the vial and lead to inaccurate dosing.

2. The nurse is caring for a comatose client. Which assessment finding provides the greatest indication that the client has an open airway?

• A. The client has asymmetrical chest expansion
• B. Percussion reveals dullness over the lung area
• C. Bilateral breath sounds can be auscultated
• D. The client has been turned q2h

Correct answer: C

Rationale: The correct answer is C: "Bilateral breath sounds can be auscultated." This finding indicates that air is moving adequately in and out of both lungs, confirming an open airway. Options A, B, and D are incorrect. Asymmetrical chest expansion may indicate lung or chest wall abnormalities, percussion revealing dullness over the lung area may suggest consolidation or fluid, and turning the client q2h is a position change intervention to prevent complications, not a direct assessment of airway patency.

3. A client receiving chemotherapy has severe neutropenia. Which snack is best for the nurse to recommend to the client?

• A. Plain yogurt sweetened with raw honey
• B. Peanuts in the shell, roasted or unroasted
• C. Aged farmer’s cheese with celery sticks
• D. Baked apples topped with dried raisins

Correct answer: A

Rationale: The correct answer is A: Plain yogurt sweetened with raw honey. This option is the best choice for a client with severe neutropenia undergoing chemotherapy because it is less likely to harbor harmful bacteria, which could cause infections due to the weakened immune system. Peanuts in the shell (choice B) may carry a risk of contamination, while aged farmer's cheese with celery sticks (choice C) and baked apples topped with dried raisins (choice D) may not be as safe as plain yogurt for a client with severe neutropenia.

4. The healthcare provider prescribes amoxicillin (Amoxil) 1.5 grams PO daily, in equally divided doses to be administered every 8 hours. The medication is available in a bottle labeled, “Amoxicillin (Amoxil) suspension 200 mg/5 ml.” How many ml should the nurse administer every 8 hours? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

• A. 12.5
• B. 7.5
• C. 10.0
• D. 15.0

Correct answer: A

Rationale: To calculate the amount in ml that the nurse should administer every 8 hours, first, determine the amount of amoxicillin needed per dose. 1.5 grams daily divided by 3 doses equals 0.5 grams per dose. Since 0.5 grams is equivalent to 500 mg (1 gram = 1000 mg), and each 5 ml of the suspension contains 200 mg of amoxicillin, the nurse needs to administer (500 mg / 200 mg) * 5 ml = 12.5 ml every 8 hours. Therefore, the correct answer is 12.5 ml. Choices B, C, and D are incorrect because they do not reflect the accurate calculation based on the provided information.

5. The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. What action should the nurse implement immediately?

• A. Change the dressing using a compression bandage
• B. Test fluid on the dressing for glucose
• C. Document the findings in the electronic medical record
• D. Mark drainage area with a pen and continue to monitor

Correct answer: B

Rationale: The correct action for the nurse to implement immediately upon identifying clear fluid on the surgical dressing post-lumbar surgery is to test the fluid for glucose. Clear fluid could indicate cerebrospinal fluid (CSF) leakage, and testing for glucose can help confirm this. Changing the dressing using a compression bandage (Choice A) without further assessment could lead to complications. Documenting the findings (Choice C) is important but not as immediate as confirming the presence of CSF. Marking the drainage area with a pen and monitoring (Choice D) does not address the need for immediate confirmation of CSF leakage.

Similar Questions