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. How should a healthcare professional manage a patient with respiratory distress?

• A. Administer bronchodilators
• B. Administer oxygen
• C. Check oxygen saturation
• D. Reposition the patient

Correct answer: B

Rationale: Administering oxygen is crucial in managing a patient with respiratory distress as it helps improve oxygenation and alleviate breathing difficulties. While administering bronchodilators may be beneficial in certain respiratory conditions like asthma or COPD, in a patient with respiratory distress, ensuring adequate oxygen supply takes precedence. Checking oxygen saturation is important, but the immediate intervention to address respiratory distress is providing supplemental oxygen. Repositioning the patient may be helpful in optimizing ventilation but is not the primary intervention in managing acute respiratory distress.

3. A client in end-stage osteoporosis is reporting severe pain, with a respiratory rate of 14 per minute. Which of the following medications should the nurse expect to be the highest priority to administer to the client?

• A. Promethazine
• B. Hydromorphone
• C. Ketorolac
• D. Amitriptyline

Correct answer: B

Rationale: In a client with severe pain like the one described, the priority medication to administer is a potent analgesic like hydromorphone. Hydromorphone is a strong opioid pain medication that can effectively manage severe pain. Promethazine (Choice A) is an antiemetic and antihistamine, not a pain medication. Ketorolac (Choice C) is a nonsteroidal anti-inflammatory drug (NSAID) that is contraindicated in end-stage renal disease due to its potential to cause kidney damage. Amitriptyline (Choice D) is a tricyclic antidepressant used for conditions like depression and neuropathic pain, but it is not the first-line treatment for severe acute pain.

4. A client has a new ileostomy. Which of the following actions should the nurse take?

• A. Apply a skin barrier around the stoma.
• B. Empty the pouch when it is one-third full.
• C. Change the entire pouching system weekly.
• D. Cleanse the peristomal skin with alcohol.

Correct answer: C

Rationale: Changing the entire pouching system weekly is essential for maintaining skin integrity and preventing infection. Option A is incorrect as applying a skin barrier should be done during the pouch change, not separately. Option B is incorrect as ileostomy pouches should be emptied when they are one-third to one-half full to prevent leakage. Option D is incorrect because cleansing the peristomal skin with alcohol can be too harsh and may cause skin irritation.

5. A nurse is assessing a client who has left-sided heart failure. Which of the following should the nurse identify as a manifestation of pulmonary congestion?

• A. Frothy, pink sputum
• B. Jugular vein distention
• C. Weight gain
• D. Bradypnea

Correct answer: A

Rationale: Correct! Frothy, pink sputum is a classic sign of pulmonary congestion in left-sided heart failure. This occurs due to the accumulation of fluid in the lungs, leading to the coughing up of frothy, pink-tinged sputum. Jugular vein distention (choice B) is more indicative of right-sided heart failure, where fluid backs up into the systemic circulation. Weight gain (choice C) may occur due to fluid retention, but it is not a direct manifestation of pulmonary congestion. Bradypnea (choice D) refers to abnormally slow breathing and is not specifically associated with pulmonary congestion.

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