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 charge nurse is assigning tasks to a nurse and assistive personnel for a group of clients. Which of the following tasks should the charge nurse delegate to the AP?

• A. Report ABG results to the provider
• B. Instruct a client about how to use an incentive spirometer
• C. Administer an enteral feeding to a client who has an established gastrostomy tube
• D. Monitor the color of a client’s urinary output

Correct answer: D

Rationale: The correct answer is D because monitoring the color of a client's urinary output is a task that can be safely delegated to assistive personnel. This task involves basic observation and does not require specialized nursing knowledge or skills. Choice A is incorrect because reporting ABG results to the provider requires interpretation and critical thinking skills typically performed by a nurse. Choice B is incorrect as instructing a client about how to use an incentive spirometer involves educating and assessing the client, which is a nursing responsibility. Choice C is incorrect as administering enteral feeding to a client with a gastrostomy tube requires nursing expertise to ensure proper technique and monitoring for complications.

3. A healthcare professional is planning to collect a liquid stool specimen from a client for ova and parasites. Inaccurate test results may result if the healthcare professional:

• A. Refrigerates the collected specimen
• B. Collects the specimen in a sterile container
• C. Delays the collection of the specimen
• D. Uses a non-contaminated collection container

Correct answer: A

Rationale: Refrigeration can kill the ova and parasites present in the stool specimen, leading to inaccurate test results. Storing the specimen in a cold environment can disrupt the integrity of the parasites and ova, affecting the accuracy of the test. Collecting the specimen in a sterile container (Choice B) is the correct procedure to prevent external contamination. Delaying the collection of the specimen (Choice C) may affect the freshness of the sample but does not directly impact the test results. Using a non-contaminated collection container (Choice D) is essential to maintain the sample's integrity but does not relate to the risk of killing ova and parasites through refrigeration.

4. In a client with liver cirrhosis, which symptom would be most concerning during assessment?

• A. Jaundice
• B. Ascites
• C. Hepatomegaly
• D. Altered mental status

Correct answer: D

Rationale: Altered mental status would be the most concerning symptom in a client with liver cirrhosis. It may indicate hepatic encephalopathy, a serious complication requiring immediate intervention. While jaundice, ascites, and hepatomegaly are common in liver cirrhosis, they do not directly correlate with the urgency and severity of hepatic encephalopathy as altered mental status does. Therefore, altered mental status takes priority for immediate attention and intervention.

5. A client is reporting difficulty falling asleep. Which of the following measures should the nurse recommend?

• A. Drink a cup of hot cocoa before bedtime
• B. Exercise 1 hour before going to bed
• C. Use progressive relaxation techniques at bedtime
• D. Reflect on the day's activities before going to bed

Correct answer: C

Rationale: The correct answer is to recommend the client to use progressive relaxation techniques at bedtime. Progressive relaxation techniques help reduce stress and muscle tension, which can promote better sleep. Choice A, drinking a cup of hot cocoa before bedtime, contains caffeine which can interfere with falling asleep. Choice B, exercising 1 hour before going to bed, can stimulate the body and mind, making it harder to fall asleep. Choice D, reflecting on the day's activities before going to bed, may lead to increased mental activity and prevent relaxation, making it difficult to fall asleep.

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