Nursing Elites

1. In hanging a parenteral IV fluid that is to be infused by gravity, rather than with an infusion pump, the nurse notes that the IV tubing is available in different drop factors. Which tubing is a microdrop set?

• A. 15 drops per milliliter
• B. 60 drops per milliliter
• C. 20 drops per milliliter
• D. 10 drops per milliliter

Correct answer: B

Rationale: A microdrop set delivers 60 drops per milliliter of IV fluid. This allows for a more precise control of the infusion rate. The correct choice is B because it provides the desired microdrop rate. Choices A, C, and D are incorrect. A delivers 15 drops per milliliter, which is a macrodrop set. C delivers 20 drops per milliliter, also a macrodrop set. D delivers 10 drops per milliliter, another macrodrop set. Therefore, the correct choice for a microdrop set is B.

2. A client, age 28, was recently diagnosed with Hodgkin's disease. After staging, therapy is planned to include combination radiation therapy and systemic chemotherapy with MOPP"?nitrogen mustard, vincristine (Onconvin), prednisone, and procarbazine. In planning care for this client, the nurse should anticipate which of the following side effects to contribute to a sense of altered body image?

• A. Cushingoid appearance
• B. Alopecia
• C. Temporary or permanent sterility
• D. Pathologic fractures

Correct answer: B

Rationale: The correct answer is B: Alopecia. Chemotherapy drugs like vincristine can cause alopecia, which is hair loss. This side effect can significantly impact a patient's body image. While Cushingoid appearance (A) can be a side effect of long-term steroid use, temporary or permanent sterility (C) may affect a patient's future fertility but not necessarily alter body image. Pathologic fractures (D) are not common side effects of Hodgkin's disease or its treatment and do not directly contribute to a sense of altered body image in the same way as alopecia does.

3. After administering enoxaparin (Lovenox) subcutaneously into the abdomen, which action should the nurse take?

• A. Gently rub the injection site after removing the needle
• B. Have the client maintain a side-lying position for at least five minutes
• C. Remove the needle and engage the needle safety device
• D. Apply heat to the injection site

Correct answer: C

Rationale: After administering a subcutaneous injection of enoxaparin (Lovenox) into the abdomen, the nurse should remove the needle and engage the needle safety device. Rubbing the injection site after the needle is withdrawn is not recommended as it may cause irritation and bruising. Having the client maintain a side-lying position for at least five minutes is unnecessary for a subcutaneous injection into the abdomen. Applying heat to the injection site is not indicated after administering enoxaparin subcutaneously; it could increase the risk of bleeding or bruising at the injection site.

4. During the admission assessment for a client undergoing breast augmentation, which information should the nurse prioritize reporting to the surgeon before surgery?

• A. The client is concerned about who will care for her two children while she recovers.
• B. The client has a history of postoperative dehiscence after a previous C-section.
• C. The client's statement that her last menstrual period was 8 weeks prior.
• D. The client's concerns over pain control postoperatively.

Correct answer: C

Rationale: The most important information for the nurse to report to the surgeon before surgery is the client's statement that her last menstrual period was 8 weeks prior. This information is crucial as the client may be pregnant, and a pregnancy test will need to be completed before administering any anesthetic agents. Reporting this detail ensures patient safety and prevents potential risks associated with anesthesia. Choices A, B, and D are important aspects of care but do not take precedence over the need to rule out pregnancy before surgery.

5. A female client complains to the nurse at the health department that she has fatigue, shortness of breath, and lightheadedness. Her history reveals no significant medical problems. She states that she is always on a fad diet without any vitamin supplements. Which tests should the nurse expect the client to have first?

• A. peptic ulcer studies
• B. complete blood count, including hematocrit and hemoglobin
• C. genetic testing
• D. hemoglobin electrophoresis

Correct answer: B

Rationale: The correct answer is to perform a complete blood count, including hematocrit and hemoglobin, as the initial tests to assess the client's symptoms related to fatigue, shortness of breath, and lightheadedness. These symptoms can be indicative of anemia, which can be caused by nutritional deficiencies due to fad dieting without vitamin supplements. Peptic ulcer studies, genetic testing, and hemoglobin electrophoresis are not the most appropriate initial tests for the client's presenting symptoms and history. Peptic ulcer studies are not relevant to the client's symptoms. Genetic testing is not indicated based on the client's presentation and history. Hemoglobin electrophoresis is used to diagnose specific types of anemia and is not the first-line test in this scenario. Further testing decisions should be based on the results of the initial tests, the client's history, and other relevant factors.

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