Nursing Elites

1. A nurse is preparing to administer prochlorperazine 2.5 mg IV. Available is prochlorperazine injection 5 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth)

• A. 0.5 mL
• B. 0.005 mL
• C. 0.05 mL
• D. 5 mL

Correct answer: A

Rationale: To calculate the mL needed, set up a proportion: 5 mg / 1 mL = 2.5 mg / X mL. Cross multiply to find X: 5 * X = 2.5 * 1, X = 2.5 / 5 = 0.5 mL. Therefore, the nurse should administer 0.5 mL. Choice B, 0.005 mL, is incorrect as it doesn't match the calculated result. Choice C, 0.05 mL, is incorrect as it is ten times the correct value. Choice D, 5 mL, is incorrect as it represents the total volume of the entire vial, not the amount needed for the specific dose.

2. A client with congestive heart failure taking digoxin reports nausea and refuses to eat breakfast. Which action should the nurse take first?

• A. Encourage the client to eat the toast on the breakfast tray.
• B. Administer an antiemetic.
• C. Inform the client's provider.
• D. Check the client's apical pulse.

Correct answer: D

Rationale: The correct action for the nurse to take first is to check the client's apical pulse. Nausea can be a sign of digoxin toxicity, and one of the early signs of digoxin toxicity is changes in the pulse rate. By checking the client's apical pulse, the nurse can assess if the digoxin level is too high. Encouraging the client to eat or administering an antiemetic may not address the underlying issue of digoxin toxicity. While informing the provider is important, assessing the client's condition through checking the apical pulse should be the immediate priority.

3. A nurse is teaching a newly licensed nurse about contraindications to ceftriaxone. The nurse should include that a severe allergy to which of the following medications is a contraindication to ceftriaxone?

• A. Gentamicin
• B. Clindamycin
• C. Piperacillin
• D. Sulfamethoxazole-trimethoprim

Correct answer: C

Rationale: The correct answer is C. Ceftriaxone, a cephalosporin antibiotic, has a cross-sensitivity with penicillin antibiotics like piperacillin. Therefore, a severe allergy to penicillin or penicillin-related antibiotics would be a contraindication to ceftriaxone. Choices A, B, and D are incorrect because they are not associated with a known cross-sensitivity with ceftriaxone.

4. A nurse is reviewing the laboratory values for a client who is receiving a continuous IV heparin infusion and has an aPTT of 90 seconds. Which of the following actions should the nurse prepare to take?

• A. Administer vitamin K
• B. Reduce the infusion rate
• C. Give the client a low-dose aspirin
• D. Request an INR

Correct answer: B

Rationale: An aPTT of 90 seconds is elevated, indicating a risk of bleeding due to excessive anticoagulation. The appropriate action is to reduce the infusion rate of heparin to prevent further complications. Administering vitamin K is not indicated for an elevated aPTT due to heparin therapy. Giving the client a low-dose aspirin can further increase the risk of bleeding when combined with heparin. Requesting an INR is not necessary for monitoring heparin therapy; aPTT is the more specific test for assessing heparin's therapeutic effect. Therefore, the correct action for the nurse to prepare to take is to reduce the infusion rate of heparin.

5. A nurse is providing discharge teaching to a client who has heart failure and a new prescription for digoxin 0.215 mg PO daily and furosemide 20 mg PO daily. Which of the following statements by the client indicates an understanding of the teaching?

• A. I know that blurred vision is something I will expect to happen while taking digoxin.
• B. I will measure my urine output each day and document it in my diary.
• C. I will skip a dose of my digoxin if my resting heart rate is below 72 beats per minute.
• D. I will eat fruits and vegetables that have high potassium content every day.

Correct answer: D

Rationale: Clients taking digoxin and furosemide are at risk for hypokalemia. Eating potassium-rich foods can help maintain normal potassium levels.

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