Nursing Elites

1. Before administering an intramuscular injection, the nurse's finger is stuck with the needle. Which action should the nurse take?

• A. Go to the emergency room to have blood drawn
• B. Prepare the medication using a new syringe
• C. Apply clean gloves before giving the medication
• D. Review the medical history in the client's chart

Correct answer: B

Rationale: In this scenario, if the nurse's finger is stuck with the needle before administering the injection, the correct action is to prepare the medication using a new syringe. This step is crucial to prevent contamination and ensure the safety of the patient. Going to the emergency room to have blood drawn is unnecessary and does not address the immediate issue of contamination. Applying clean gloves is important for infection control but does not address the potential contamination from the needlestick. Reviewing the medical history in the client's chart is important for overall patient care but is not the priority in this situation where immediate action is required to prevent harm.

2. What action should the nurse take after a client produces the first of a series of sputum samples for cytology?

• A. Ensure the client remains NPO until all samples are collected
• B. Transport the sputum container to the laboratory in a biohazard bag
• C. Discard the initial sample and document the time it was obtained
• D. Document the time the client last ate or drank on the laboratory slip

Correct answer: B

Rationale: The correct action for the nurse to take after a client produces the first of a series of sputum samples for cytology is to transport the sputum container to the laboratory in a biohazard bag. This is important to ensure proper handling and prevent contamination of the sample. Choice A is incorrect because there is no need to keep the client NPO until all samples are collected. Choice C is incorrect as the initial sample should not be discarded but rather transported to the laboratory. Choice D is also incorrect as documenting the time the client last ate or drank is not directly relevant to the immediate action needed for the sputum sample.

3. When taking a health history of a client admitted with acute pancreatitis, which client complaint should be expected?

• A. A low-grade fever and left lower abdominal pain
• B. Severe headache and sweating all the time
• C. Severe mid-epigastric pain after ingesting a heavy meal
• D. Dull, continuous, right lower quadrant pain and nausea

Correct answer: C

Rationale: The correct answer is C: 'Severe mid-epigastric pain after ingesting a heavy meal.' This symptom is characteristic of acute pancreatitis due to inflammation of the pancreas, which often presents with severe pain in the mid-epigastric region that may worsen after eating. Choices A, B, and D describe symptoms that are not typically associated with acute pancreatitis. A low-grade fever and left lower abdominal pain (Choice A) may be more indicative of other conditions like diverticulitis. Severe headache and sweating (Choice B) are commonly seen in conditions like migraines or infections. Dull, continuous, right lower quadrant pain and nausea (Choice D) could be suggestive of appendicitis rather than acute pancreatitis.

4. The nurse is caring for a newborn who arrives in the nursery following a precipitous birth on the way to the hospital. A drug screen of the mother reveals the presence of cocaine metabolites. The infant has a heart rate of 175 beats/minute, cries continuously, is irritable, and is hyperreactive to stimuli. Which intervention is most important for the nurse to include in this infant’s plan of care?

• A. Initiate infant sepsis protocol
• B. Implement seizure precautions
• C. Refer to protective child services
• D. Formula feed every 3 hours

Correct answer: B

Rationale: The infant's symptoms, such as a high heart rate, continuous crying, irritability, and hyperreactivity, suggest possible withdrawal effects due to maternal cocaine use. These symptoms can lead to seizures. Therefore, the priority intervention is to implement seizure precautions to ensure the infant's safety. Initiating the infant sepsis protocol is not indicated based on the symptoms presented. Referring to protective child services is important but not the immediate priority. Formula feeding every 3 hours is a routine care measure but does not address the urgent need to prevent potential seizures.

5. An infant is receiving penicillin G procaine 220,000 units IM. The drug is supplied as 600,000 units/ml. How many ml should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth)

• A. 0.4
• B.
• C.
• D.

Correct answer: A

Rationale: To calculate the volume to administer, use the formula: Desired dose (220,000 units) / Dose on hand (600,000 units) x Volume of the available dose (1 ml). This results in 0.4 ml to be administered. Choice A is correct. Choice B, C, and D are incorrect as they are not provided.

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