Nursing Elites

1. A nurse in a surgical suite notes documentation on a client's medical record stating that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?

• A. Ensure sterilization of non-disposable items with ethylene oxide
• B. Wrap monitoring cords with stockinette and secure them with non-latex tape
• C. Cleanse latex ports on IV tubing with chlorhexidine before administering medication
• D. Wear hypoallergenic latex gloves that are powder-free

Correct answer: B

Rationale: In this scenario, the nurse should take precautions to prevent latex exposure to the client due to his latex allergy. Wrapping monitoring cords with stockinette and securing them with non-latex tape helps to minimize the risk of latex contact with the client. Choice A is incorrect as sterilizing non-disposable items with ethylene oxide does not specifically address the avoidance of latex exposure. Choice C involves using latex ports on IV tubing, which can pose a risk of allergic reaction in a client with a latex allergy. Choice D suggests wearing latex gloves, even if hypoallergenic, which can still trigger a reaction in individuals with latex allergy. Therefore, the best option is to choose non-latex materials like stockinette and non-latex tape to prevent direct contact with latex.

2. The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO. Zaroxolyn is available in 5 mg tablets. How much should the LPN/LVN plan to administer?

• A. 1/2 tablet.
• B. 1 tablet.
• C. 1 1/2 tablets.
• D. 2 tablets.

Correct answer: C

Rationale: To administer 7.5 mg of metolazone (Zaroxolyn), the LPN/LVN should plan to give 1 1/2 tablets since each tablet contains 5 mg. Choice A (1/2 tablet) would not provide the full prescribed dose. Choice B (1 tablet) would only deliver 5 mg, which is less than the prescribed dose. Choice D (2 tablets) would exceed the prescribed dose, resulting in 10 mg instead of the required 7.5 mg. Therefore, the correct answer is to administer 1 1/2 tablets to achieve the prescribed 7.5 mg.

3. A healthcare professional is reviewing measures to prevent back injuries with assistive personnel (AP). Which of the following instructions should the healthcare professional include?

• A. When lifting an object, spread your feet apart to provide a wide base of support.
• B. Always lift objects with your back straight and not your legs.
• C. Avoid using any assistive devices.
• D. Bend at the waist to reach objects.

Correct answer: A

Rationale: The correct instruction to prevent back injuries while lifting is to spread your feet apart to provide a wide base of support. This helps in maintaining stability and reduces the risk of back injury. Choice B is incorrect as lifting objects with your back straight and using your legs is the recommended technique. Choice C is incorrect because assistive devices can actually help prevent back injuries by providing support. Choice D is incorrect as bending at the waist to reach objects can strain the back muscles and increase the risk of injury.

4. The healthcare provider is monitoring a client in active labor. Which pattern on the fetal heart monitor requires immediate intervention?

• A. Early decelerations
• B. Late decelerations
• C. Accelerations
• D. Moderate variability

Correct answer: B

Rationale: Late decelerations are concerning as they indicate uteroplacental insufficiency, potentially resulting in fetal hypoxia. Immediate intervention is necessary to address the underlying cause and ensure fetal well-being. Early decelerations are typically benign and associated with head compression during contractions. Accelerations are reassuring and indicate fetal well-being. Moderate variability is a normal finding and indicates a healthy autonomic nervous system response. Therefore, late decelerations (Choice B) require immediate attention, while the other patterns are generally considered normal or benign during labor.

5. The healthcare provider is assessing a client with a history of congestive heart failure. Which assessment finding would be most concerning?

• A. Shortness of breath on exertion
• B. Weight gain of 2 pounds in a week
• C. Orthopnea
• D. Crackles in the lungs

Correct answer: D

Rationale: Crackles in the lungs are concerning because they indicate pulmonary congestion, a serious complication of congestive heart failure. The presence of crackles suggests fluid accumulation in the lungs, requiring immediate attention to prevent respiratory distress and worsening heart failure. While shortness of breath on exertion, weight gain, and orthopnea are common signs and symptoms of heart failure, crackles specifically point to acute pulmonary edema or worsening congestion, making them the most concerning finding in this scenario.

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