Nursing Elites

1. A healthcare provider orders a medication dose three times higher than usual. What is the nurse's first step?

• A. Administer the medication but monitor the patient closely.
• B. Verify the dosage with the prescribing provider.
• C. Administer a lower dose to minimize the risk.
• D. Hold the medication and wait for further clarification.

Correct answer: B

Rationale: The correct answer is B: Verify the dosage with the prescribing provider. When faced with an unusual medication dose, the nurse's initial action should be to confirm the order with the healthcare provider who prescribed it. This step is crucial to prevent medication errors and ensure patient safety. Choices A, C, and D are incorrect because administering the medication without clarification, administering a lower dose without approval, or holding the medication without consulting the provider can all pose risks to the patient's well-being.

2. A client with pneumonia is receiving oxygen therapy. Which of the following oxygen delivery devices should be used to deliver a precise oxygen concentration?

• A. Nasal cannula
• B. Simple face mask
• C. Venturi mask
• D. Non-rebreather mask

Correct answer: C

Rationale: A Venturi mask should be used to deliver a precise oxygen concentration to a client with pneumonia. Venturi masks are designed to deliver a specific oxygen concentration by mixing oxygen with room air in a precise ratio. This device is ideal for patients who require accurate oxygen delivery, such as those with chronic lung diseases. Nasal cannulas deliver a lower concentration of oxygen and are more suitable for patients with mild respiratory issues. Simple face masks and non-rebreather masks do not provide as precise control over the oxygen concentration as a Venturi mask.

3. A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?

• A. Inject at a 90-degree angle
• B. Inject at a 45-degree angle
• C. Massage the injection site after administering
• D. Use a longer needle

Correct answer: B

Rationale: The correct answer is to inject enoxaparin subcutaneously at a 45-degree angle. This angle helps ensure proper delivery of the medication into the subcutaneous tissue. Option A (Inject at a 90-degree angle) is incorrect because subcutaneous injections are usually given at a shallower angle. Option C (Massage the injection site after administering) is incorrect as massaging the site can cause bruising and should generally be avoided. Option D (Use a longer needle) is incorrect as using a longer needle is unnecessary and may increase the risk of injecting the medication too deeply.

4. A nurse is caring for a client who is in labor and has an external fetal monitor in place. The nurse observes late decelerations in the fetal heart rate. Which of the following actions should the nurse take first?

• A. Decrease the client's IV fluids
• B. Reposition the client
• C. Administer oxygen by face mask
• D. Document the findings

Correct answer: C

Rationale: Administering oxygen by face mask is the priority intervention when late decelerations are observed in the fetal heart rate. Late decelerations indicate uteroplacental insufficiency, and administering oxygen helps to improve fetal oxygenation. Repositioning the client may also be necessary to relieve pressure on the umbilical cord, but providing oxygen takes precedence to enhance fetal oxygenation. Decreasing IV fluids may not directly address the underlying issue leading to late decelerations. Documenting the findings is important but should not be the first action taken when managing late decelerations.

5. A healthcare provider is reviewing the laboratory report of a client who is receiving heparin therapy for a deep vein thrombosis. Which of the following lab values indicates a therapeutic response to the therapy?

• A. PT of 12 seconds
• B. aPTT of 70 seconds
• C. Platelets of 150,000/mm3
• D. INR of 1.5

Correct answer: B

Rationale: An aPTT of 70 seconds is within the therapeutic range for a client receiving heparin therapy. The activated partial thromboplastin time (aPTT) is the most sensitive test to monitor heparin therapy. A therapeutic aPTT range for a client receiving heparin is usually 1.5 to 2.5 times the control value. Choices A, C, and D are not indicators of a therapeutic response to heparin therapy. PT measures the extrinsic pathway of coagulation and is not specific to monitoring heparin therapy. Platelet count is important to monitor for heparin-induced thrombocytopenia, but it does not indicate the therapeutic response to heparin therapy. INR is used to monitor warfarin therapy, not heparin therapy.

Similar Questions