Nursing Elites

1. The healthcare provider prescribes 1,000 ml of Ringer's Lactate with 30 Units of Pitocin to run over 4 hours for a client who has just delivered a 10-pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration set. The LPN/LVN plans to set the flow rate at how many gtt/min?

• A. 42 gtt/min
• B. 83 gtt/min
• C. 125 gtt/min
• D. 250 gtt/min

Correct answer: B

Rationale: To calculate the flow rate in drops per minute (gtt/min), the formula is Total volume (mL) ÷ Time (min) ÷ Drop factor (gtt/mL). In this case, 1000 mL ÷ 240 min ÷ 20 gtt/mL = 83 gtt/min. Therefore, setting the flow rate to 83 gtt/min ensures the correct administration of the IV fluids and medication. Choices A, C, and D are incorrect as they do not align with the correct calculation based on the provided information.

2. A client with a new colostomy is being taught how to irrigate the ostomy. The healthcare provider realizes that the client needs further teaching when the client:

• A. Positions the irrigating solution bag 30 inches below the stoma
• B. Uses an open system for irrigation
• C. Irrigates the colostomy twice a day
• D. Cleans the stoma with harsh chemicals

Correct answer: A

Rationale: The correct answer is A. Positioning the irrigating solution bag 30 inches below the stoma would cause discomfort and ineffective irrigation as the bag should be positioned at a lower level. Option B is incorrect because a closed system for irrigation is the preferred method for colostomy irrigation. Option C is incorrect as colostomy irrigation is typically done once a day unless otherwise instructed by a healthcare provider. Option D is incorrect as the stoma should be cleaned with mild soap and water to prevent skin irritation and damage.

3. The patient refuses to bathe in the morning, stating a preference for evening baths. What is the best action for the nurse?

• A. Defer the bath until evening and pass on the information to the next shift.
• B. Tell the patient that daily morning baths are part of the 'normal' routine.
• C. Explain the importance of maintaining morning hygiene practices.
• D. Cancel hygiene for the day and attempt again in the morning.

Correct answer: A

Rationale: The best action by the nurse is to respect the patient's preference and autonomy. Defer the bath until evening to allow the patient to follow their usual hygiene routine. Passing on the information to the next shift ensures continuity of care. Choice B is incorrect because it disregards the patient's preference and autonomy. Choice C, while important, does not address the patient's immediate concern. Choice D is incorrect as it does not respect the patient's wishes and may lead to further resistance to bathing.

4. After a renal biopsy, a client has returned to the unit. Which of the following nursing interventions is appropriate?

• A. Ambulate the client 4 hours after the procedure
• B. Maintain the client on NPO status for 24 hours
• C. Monitor vital signs
• D. Change the dressing every 8 hours

Correct answer: C

Rationale: Monitoring vital signs is crucial after a renal biopsy to promptly detect any signs of bleeding or complications. Ambulating the client 4 hours after the procedure may increase the risk of bleeding, so it is not appropriate. Maintaining the client on NPO status for 24 hours is not necessary unless specifically ordered by the healthcare provider. Changing the dressing every 8 hours is not typically indicated unless there is a specific concern or order to do so.

5. A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process?

• A. Obtain client information
• B. Develop a plan of care
• C. Implement nursing interventions
• D. Evaluate the client's response to treatment

Correct answer: A

Rationale: The correct answer is A: Obtain client information. The first step in the nursing process is assessment, which involves gathering data about the client's condition, needs, and preferences. This information forms the foundation for developing a comprehensive plan of care. Developing a plan of care (Choice B) comes after assessment to address the identified needs. Implementing nursing interventions (Choice C) follows the development of the plan of care. Evaluating the client's response to treatment (Choice D) occurs after implementing the interventions to determine the effectiveness of the care provided. Therefore, the initial and priority step is to obtain client information through assessment.

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