Nursing Elites

1. An 8-year-old child who weighs 60 pounds receives an order for Polycilin (Ampicillin) suspension 25 mg/kg/day divided into a dose every 8 hours. The medication is labeled '125 mg/5 ml'. How many ml should the nurse administer per dose every 8 hours?

• A. 5
• B. 10
• C. 15
• D. 20

Correct answer: A

Rationale: Calculate the daily dose first: 60 pounds x 25 mg/kg = 1500 mg/day. Divide by 3 doses = 500 mg/dose. Convert to mL: (500 mg / 125 mg) x 5 ml = 20 ml. However, the question asks for the dose per administration every 8 hours, which is 1/3 of the daily dose. So, the correct calculation should be (20 ml / 3) = 6.67 ml, which rounds to 5 ml. Therefore, the correct answer is 5 ml. Choice B (10 ml) is incorrect because it doesn't consider the frequency of dosing. Choice C (15 ml) is incorrect as it overestimates the dose. Choice D (20 ml) is incorrect as it represents the total daily dose, not the dose per administration every 8 hours.

2. A client with a severe prostatic infection that caused a blocked urethra is 3 days post-surgical urinary diversion. The healthcare provider directs the nurse to remove the suprapubic catheter to allow the client to void normally. Which intervention should the nurse implement first?

• A. Cleanse the site around the catheter
• B. Use a 20 ml syringe to deflate balloon
• C. Clamp catheter until the client voids naturally
• D. Empty urine from the urinary drainage bag

Correct answer: B

Rationale: The correct answer is to use a 20 ml syringe to deflate the balloon first when removing a suprapubic catheter. This step is essential to ensure the safe removal of the catheter without causing any harm or discomfort to the client. Deflating the balloon allows for the catheter to be easily removed. Option A, cleansing the site around the catheter, is not the initial step in this process and can be done after catheter removal. Option C, clamping the catheter until the client voids naturally, is incorrect as it can lead to complications like urinary retention. Option D, emptying urine from the urinary drainage bag, is not the first step in removing the suprapubic catheter and does not address the need to deflate the balloon for safe removal.

3. Based on the information provided in this client’s medical record during labor, which intervention should the nurse implement?

• A. Apply oxygen at 10 L per minute via mask
• B. Stop the oxytocin infusion
• C. Turn the client to the right lateral position
• D. Continue monitoring the progress of labor

Correct answer: C

Rationale: Turning the client to the right lateral position is essential as it can improve fetal oxygenation and uterine blood flow, promoting better labor outcomes. This intervention helps relieve pressure on blood vessels, enhancing blood flow to the placenta and improving oxygen supply to the fetus. Applying oxygen at a specific rate may not address the underlying issue of compromised blood flow and oxygenation. Stopping the oxytocin infusion is not the priority unless medically indicated as it can affect labor progression. While monitoring the progress of labor is important, actively addressing the compromised fetal oxygenation and uterine blood flow by changing the client's position takes precedence in this scenario.

4. An elderly client with Alzheimer's disease is being admitted to a long-term care facility. The client’s spouse expresses concern about the level of care the client will receive. What is the most appropriate response by the nurse?

• A. Reassure the spouse that the client will be well cared for and provide information about the facility’s care practices.
• B. Inform the spouse that care will be adjusted based on the client’s condition and needs.
• C. Advise the spouse to visit frequently to monitor the quality of care the client receives.
• D. Suggest that the spouse speak with other family members for reassurance.

Correct answer: A

Rationale: The most appropriate response by the nurse in this situation is to reassure the spouse that the client will be well cared for and provide information about the facility’s care practices. This response not only addresses the spouse's concerns directly but also helps in building trust and confidence in the care provided. Choice B is not ideal as it may cause unnecessary worry about the fluctuating care levels. Choice C puts the responsibility on the spouse to monitor care, which may not always be feasible or appropriate. Choice D deflects the concern to other family members instead of addressing the spouse's worries directly.

5. While changing the pressure ulcer dressing of a client who is immobile, the nurse notes that the boundary edges of the wound have increased. Before reporting this finding to the healthcare provider, the nurse should review which of the client’s serum laboratory values?

• A. Potassium
• B. Platelets
• C. Creatinine
• D. Albumin

Correct answer: D

Rationale: The correct answer is D: Albumin. Reviewing albumin levels is crucial in this situation because low albumin levels can impact wound healing and contribute to increased wound edges. Potassium (choice A) is not directly related to wound healing or wound edges. Platelets (choice B) are more related to blood clotting than wound healing. Creatinine (choice C) is related to kidney function, not specifically to wound healing or wound edges.

Similar Questions