Nursing Elites

1. A patient took an overdose of acetaminophen. Which of the following medications should the nurse plan to administer to the patient?

• A. Naloxone
• B. Acetylcysteine
• C. Flumazenil
• D. Activated charcoal

Correct answer: B

Rationale: Acetylcysteine is the antidote for acetaminophen overdose. It works by replenishing glutathione, a key component in detoxifying acetaminophen metabolites, thus preventing liver damage. Naloxone is used to reverse opioid overdose, not acetaminophen. Flumazenil is a benzodiazepine antidote. Activated charcoal is used to limit absorption in cases of poisoning, but it is not the antidote for acetaminophen overdose.

2. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displays toxicity. Which of the following actions should the nurse take?

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

Correct answer: D

Rationale: In cases of magnesium sulfate toxicity, calcium gluconate is the antidote that should be administered promptly. Positioning the client supine (Choice A) is not the priority in this scenario. Administering dextrose 5% in water (Choice B) is not indicated for magnesium sulfate toxicity. Methylergonovine IM (Choice C) is used for postpartum hemorrhage, not for magnesium sulfate toxicity.

3. What are the key components of a focused respiratory assessment, and how do you recognize signs of respiratory distress?

• A. Inspection, Palpation, Percussion, Auscultation
• B. Palpation, Inspection, Observation, Auscultation
• C. Percussion, Inspection, Auscultation, Palpation
• D. Inspection, Percussion, Auscultation, Palpation

Correct answer: A

Rationale: The correct answer is A: Inspection, Palpation, Percussion, Auscultation. A focused respiratory assessment should start with inspection (observing the breathing pattern), followed by palpation (feeling for abnormalities like crepitus), percussion (evaluating for dullness or hyperresonance), and auscultation (listening to lung sounds). This systematic approach helps to identify signs of respiratory distress, such as abnormal breath sounds, increased respiratory rate, use of accessory muscles, and cyanosis. Choices B, C, and D are incorrect because they do not follow the standard order and sequence of a focused respiratory assessment.

4. A client with IV fluids has developed redness and warmth at the IV site. What is the next step the nurse should take?

• A. Apply a cold compress to the IV site
• B. Discontinue the IV and notify the healthcare provider
• C. Monitor the IV site for signs of infection
• D. Increase the IV flow rate to improve circulation

Correct answer: B

Rationale: When a client develops redness and warmth at the IV site, it is indicative of phlebitis, which is inflammation of the vein. The next step for the nurse should be to discontinue the IV and notify the healthcare provider. Applying a cold compress may provide temporary relief but does not address the underlying issue. Monitoring for infection is important, but in this case, the presence of redness and warmth suggests phlebitis, not infection. Increasing the IV flow rate can exacerbate the inflammation and should be avoided.

5. A nurse is preparing to administer insulin to a client who has type 1 diabetes mellitus. After drawing up the medication, the nurse accidentally brushes the needle on the counter's surface. Which of the following actions should the nurse take?

• A. Prepare a new dose of insulin injection
• B. Administer the insulin as it is
• C. Wipe the needle with an alcohol swab
• D. Ask the provider for guidance

Correct answer: A

Rationale: The correct action for the nurse to take is to prepare a new dose of insulin injection. Accidentally brushing the needle on a contaminated surface can lead to infection risk. Administering the insulin as it is or just wiping the needle with an alcohol swab would not be sufficient to eliminate the risk of infection. Asking the provider for guidance is not necessary in this situation as the nurse can independently take the appropriate action to ensure patient safety.

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