Nursing Elites

1. A nurse is caring for a client who has been prescribed methadone. Which of the following client statements indicates a need for further teaching?

• A. I understand methadone slows my breathing.
• B. I understand methadone may cause me to have trouble sleeping.
• C. I will avoid alcohol while I’m taking this medication.
• D. I’ll change positions slowly, especially when standing.

Correct answer: B

Rationale: The correct answer is B because methadone typically causes sedation and respiratory depression, not trouble sleeping. The statement about trouble sleeping indicates a need for further teaching. Choices A, C, and D are incorrect because understanding that methadone slows breathing, avoiding alcohol while taking the medication, and changing positions slowly to prevent dizziness are all appropriate client statements when prescribed methadone.

2. A nurse is planning to discharge a client who has quadriplegia to his home. The nurse suggests that the family might need respite care services. When a family member asks how respite care can help, which response should the nurse provide?

• A. Respite care provides medical support to the client.
• B. Respite care assists with financial planning for the client’s needs.
• C. Respite care provides long-term housing.
• D. Respite care allows the primary caregiver time away from day-to-day care responsibilities.

Correct answer: D

Rationale: The correct answer is D. Respite care is designed to give primary caregivers temporary relief from the responsibilities of care, allowing them to take a break. Choice A is incorrect because respite care is not primarily focused on providing medical support to the client. Choice B is incorrect as respite care does not specifically assist with financial planning for the client's needs. Choice C is incorrect as respite care does not provide long-term housing, but rather short-term relief for caregivers.

3. A client with severe preeclampsia is receiving magnesium sulfate intravenously. Which action should the nurse take when toxicity occurs?

• A. Position the client supine
• B. Prepare an IV bolus of dextrose 5%
• C. Administer calcium gluconate IV
• D. Administer methylergonovine IM

Correct answer: C

Rationale: When toxicity from magnesium sulfate occurs, the nurse should administer calcium gluconate IV as it is the antidote for magnesium sulfate toxicity. Positioning the client supine may not address the toxicity issue. Administering dextrose 5% is not the appropriate intervention for magnesium sulfate toxicity. Methylergonovine is used to manage postpartum hemorrhage and is not indicated for magnesium sulfate toxicity.

4. A healthcare professional is preparing to administer ceftriaxone. Which of the following actions should the healthcare professional take?

• A. Reconstitute the medication with normal saline
• B. Reconstitute the medication with sterile water
• C. Administer the medication over 30 minutes
• D. Monitor for signs of toxicity

Correct answer: B

Rationale: Correct Answer: B. Ceftriaxone should be reconstituted with sterile water, not saline. Reconstituting it with normal saline can result in a chemical interaction and precipitation of the drug. Administering the medication over 30 minutes (choice C) is not necessary as ceftriaxone is usually given as an intravenous bolus or drip over a shorter period. Monitoring for signs of toxicity (choice D) is important but not the immediate action required for preparing the medication. The priority is to ensure proper reconstitution with the appropriate solvent, which is sterile water.

5. A nurse is developing a plan of care for a client who will be placed in halo traction following surgical repair of the cervical spine. Which of the following interventions should the nurse include in the plan?

• A. Inspect the pin site every 4 hours
• B. Monitor the client’s skin under the halo vest
• C. Ensure two personnel hold the halo device when repositioning the client
• D. Apply powder frequently to the client’s skin under the vest to decrease itching

Correct answer: B

Rationale: The correct answer is to monitor the client’s skin under the halo vest. This is important to assess for signs of skin issues such as excessive sweating, redness, or blistering, which can lead to skin breakdown and infection. Choice A is incorrect because inspecting the pin site every 4 hours is necessary but not the priority in this case. Choice C is incorrect as it is not essential for two personnel to hold the halo device during repositioning. Choice D is incorrect because applying powder frequently can actually increase the risk of skin issues by clogging pores and causing irritation.

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