Nursing Elites

1. A nurse is preparing to administer an IV medication to a client who has an allergy to latex. Which of the following actions should the nurse take?

• A. Use latex gloves when administering the medication.
• B. Use latex-free syringes when administering the medication.
• C. Administer the medication through a latex-free IV port.
• D. Administer the medication with a latex-free syringe.

Correct answer: C

Rationale: The correct action for the nurse to take when preparing to administer IV medication to a client with a latex allergy is to administer the medication through a latex-free IV port. This is crucial as it prevents direct contact of the medication with latex, reducing the risk of an allergic reaction. Choice A is incorrect as using latex gloves can still expose the client to latex. Choice B is not the best option since the administration route is not specified, and using a latex-free syringe alone may not be sufficient to prevent exposure. Choice D is not the most appropriate because the IV tubing and ports should also be latex-free to ensure complete avoidance of latex contact.

2. A nurse is preparing to administer digoxin to a client who has heart failure. Which of the following findings should the nurse report to the provider?

• A. Potassium 4.0 mEq/L
• B. Calcium 9.5 mg/dL
• C. Heart rate of 60/min
• D. Sodium 140 mEq/L

Correct answer: C

Rationale: The correct answer is C: Heart rate of 60/min. A heart rate of 60/min is borderline bradycardia, which can be a sign of digoxin toxicity. Digoxin can cause bradycardia, so any further decrease in heart rate should be reported promptly to the healthcare provider. Choices A, B, and D are within the normal range and not specifically related to potential digoxin toxicity, so they do not require immediate reporting.

3. A nurse in a pediatric unit is preparing to insert an IV catheter for a 7-year-old. Which of the following actions should the nurse take?

• A. Allow the child to handle the IV supplies to become familiar with them.
• B. Tell the child they will feel discomfort during the catheter insertion.
• C. Use a mummy restraint to hold the child during the catheter insertion.
• D. Require the parents to leave the room during the procedure.

Correct answer: B

Rationale: The correct answer is B because informing the child that they will feel discomfort during catheter insertion is crucial to prepare them for the procedure. Choice A is incorrect as children should not handle medical supplies. Choice C is inappropriate as using a restraint can cause anxiety and fear in the child. Choice D is not necessary as having parents present can provide comfort and support to the child during the procedure.

4. A nurse in a mental health facility is caring for a client who is angry and throwing objects at staff members. Which of the following actions should the nurse take?

• A. Ask the client to identify what made them angry.
• B. Instruct the client to calm down.
• C. Place the client in seclusion.
• D. Encourage the client to attend group therapy.

Correct answer: C

Rationale: During a situation where a client is exhibiting violent behavior like throwing objects and posing a risk to themselves and others, the immediate priority is to ensure the safety of all involved. Placing the client in seclusion is a necessary intervention to prevent harm and allow for de-escalation. Asking the client to identify the trigger or instructing them to calm down may not be effective or safe in this escalated state. Encouraging the client to attend group therapy is not suitable when they are in an agitated and aggressive state that requires immediate intervention.

5. What is the primary nursing action for a patient with confusion post-surgery?

• A. Administer oxygen
• B. Reposition the patient
• C. Monitor vital signs
• D. Check oxygen saturation

Correct answer: A

Rationale: Administering oxygen is the primary nursing action for a patient with confusion post-surgery because it helps address any potential hypoxia that may be contributing to the patient's confusion. While repositioning the patient, monitoring vital signs, and checking oxygen saturation are important nursing interventions, administering oxygen takes precedence in ensuring adequate oxygenation levels, which is crucial in managing post-surgery confusion.

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