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 has pharyngeal diphtheria. What transmission precautions are necessary?

• A. Droplet
• B. Contact
• C. Airborne
• D. Standard

Correct answer: A

Rationale: Pharyngeal diphtheria is primarily spread through droplet transmission, which occurs when an infected person coughs, sneezes, or talks, releasing respiratory droplets containing the bacteria. Therefore, the correct precaution for caring for a client with pharyngeal diphtheria is droplet precautions. Droplet precautions help prevent the transmission of respiratory pathogens over short distances via respiratory droplets. Contact precautions are used for diseases spread through direct or indirect contact with the patient or their environment. Airborne precautions are used for diseases that spread through small droplets suspended in the air. Standard precautions are basic infection prevention practices applying to all patient care.

3. A client who is postoperative is using an incentive spirometer. Into which of the following positions should the nurse place the client?

• A. Side-lying
• B. Supine
• C. Semi-Fowler’s
• D. Trendelenburg

Correct answer: C

Rationale: The correct position for a postoperative client using an incentive spirometer is the Semi-Fowler’s position. Placing the client in Semi-Fowler’s or high-Fowler’s position maximizes lung expansion and the effectiveness of the incentive spirometer. Side-lying may not provide optimal lung expansion. The supine position is not ideal for postoperative clients using incentive spirometers as it may limit lung expansion. The Trendelenburg position is not recommended due to potential complications postoperatively.

4. A male client presents to the clinic stating that he has a high-stress job and is having difficulty falling asleep at night. The client reports having a constant headache and is seeking medication to help with sleep. Which intervention should the nurse implement?

• A. Determine the client's sleep and activity pattern
• B. Obtain a prescription for the client to take when stressed
• C. Refer the client for a sleep study and neurological follow-up
• D. Teach coping strategies to use when feeling stressed

Correct answer: A

Rationale: The correct intervention for the nurse to implement in this scenario is to determine the client's sleep and activity pattern. By assessing the client's patterns, the nurse can identify factors contributing to the sleep issues and tailor appropriate interventions. Choice B is incorrect because prescribing medication without a comprehensive assessment is not the initial step. Choice C is unnecessary at this stage as the client's symptoms are likely related to stress rather than a neurological disorder. Choice D, while important, should come after understanding the client's sleep patterns to provide holistic care. Therefore, option A is the best choice to address the client's sleep difficulties and headaches effectively.

5. A patient with stomatitis is receiving oral care education from a nurse. Which instructions will the nurse provide?

• A. Avoid commercial mouthwashes.
• B. Avoid normal saline rinses.
• C. Brush with a hard toothbrush.
• D. Brush with an alcohol-based toothpaste.

Correct answer: A

Rationale: The correct instruction for a patient with stomatitis is to avoid commercial mouthwashes. Commercial mouthwashes often contain alcohol and other ingredients that can irritate the already inflamed oral mucosa in patients with stomatitis. Avoiding commercial mouthwashes helps prevent further irritation and discomfort. Choice B is incorrect because normal saline rinses are gentle and can help soothe the oral mucosa in patients with stomatitis. Choice C is incorrect because a soft toothbrush should be used to prevent further irritation or injury to the gums. Choice D is incorrect because an alcohol-based toothpaste can be too harsh and drying for patients with stomatitis.

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