Nursing Elites

1. The healthcare provider prescribes Cytovene 375 mg every 12 hours to infuse over 90 minutes. The pharmacy delivers Cytovene 375 mg in a 150 mL IV bag. How many ml/hour should the nurse program the infusion pump?

• A. 50 ml/hour.
• B. 75 ml/hour.
• C. 100 ml/hour.
• D. 125 ml/hour.

Correct answer: C

Rationale: To infuse 150 mL over 90 minutes, the pump should be set to 100 ml/hour (150 mL / 1.5 hours). This rate ensures that the medication is delivered at the proper rate as prescribed. Choices A, B, and D are incorrect because they do not reflect the correct calculation based on the volume of the IV bag and the infusion duration provided in the question.

2. In the change of shift report, the nurse is told that a client has a stage 2 pressure ulcer. Which ulcer appearance is most likely to be observed?

• A. Shallow open ulcer with a red-pink wound bed.
• B. Intact skin with non-blanchable redness.
• C. Full-thickness tissue loss with visible fat.
• D. Full-thickness tissue loss with exposed bone, tendon, or muscle.

Correct answer: A

Rationale: The correct answer is A: 'Shallow open ulcer with a red-pink wound bed.' Stage 2 pressure ulcers involve partial-thickness skin loss and typically appear as shallow open ulcers with a red-pink wound bed. Choice B describes a stage 1 ulcer, where the skin is intact but shows non-blanchable redness. Choice C describes a stage 3 ulcer, with full-thickness tissue loss exposing fat. Choice D is characteristic of a stage 4 ulcer, where there is full-thickness tissue loss exposing bone, tendon, or muscle. Therefore, option A best fits the description of a stage 2 pressure ulcer.

3. An adolescent female asks the nurse about taking retinoic acid (Accutane). What guidance should be provided by the nurse?

• A. The medication should be used for 10 weeks only.
• B. The medication requires that sexually active females use contraception.
• C. The medication lowers hemoglobin levels very quickly.
• D. The medication has few side effects.

Correct answer: B

Rationale: The correct guidance the nurse should provide is that sexually active females must use contraception while taking Accutane and for 1 month after the 20 weeks it is prescribed. Choice A is incorrect because Accutane is typically taken for a longer duration than 10 weeks. Choice C is incorrect because Accutane does not lower hemoglobin levels quickly. Choice D is incorrect as Accutane is known for having many side effects, including the risk of birth defects.

4. A community hit by a hurricane has suffered mass destruction and flooding. Several facilities are not functioning, and the area is contaminated with human excretions. The nurse is developing a plan of care for clients diagnosed with cholera after an outbreak. Which intervention has the highest priority?

• A. Administer prophylactic antibiotics as prescribed.
• B. Provide fluid and electrolyte replacement.
• C. Isolate all infectious diarrhea victims.
• D. Administer cholera vaccine.

Correct answer: B

Rationale: Providing fluid and electrolyte replacement is the highest priority to prevent dehydration and shock in clients with cholera. Administering prophylactic antibiotics may be necessary but is not the highest priority. Isolating infectious diarrhea victims is important for preventing the spread of infection, but addressing fluid and electrolyte imbalances takes precedence. Administering a cholera vaccine is preventive and not the immediate priority in treating clients already diagnosed with cholera.

5. During a paracentesis, two liters of fluid are removed from the abdomen of a client with ascites. A drainage bag is placed, and 50 ml of straw-colored fluid drains within the first hour. What action should the nurse implement?

• A. Palpate for abdominal distention
• B. Send fluid to the lab for analysis
• C. Continue to monitor the fluid output
• D. Clamp the drainage tube for 5 minutes

Correct answer: C

Rationale: Continuing to monitor the fluid output is the appropriate action in this situation. Monitoring the fluid output helps the nurse assess the client's ongoing response to the procedure and detect any sudden changes, such as increased or decreased drainage rate, which could indicate complications. Palpating for abdominal distention, sending fluid to the lab for analysis, or clamping the drainage tube are not necessary actions at this point, as the priority is to monitor the client's condition post-procedure.

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