Nursing Elites

1. The healthcare provider prescribes erythromycin (Ilosone) 300 mg PO QID. The medication label reads, 'Ilosone 100mg/5mL.' How many mL should the nurse administer at each dose?

• A. 15 mL
• B. 10 mL
• C. 20 mL
• D. 5 mL

Correct answer: A

Rationale: To determine the volume of medication needed for a 300 mg dose of Ilosone (100mg/5mL), we set up a proportion: 100 mg is to 5 mL as 300 mg is to x mL. Cross-multiplying, we get x = (300*5)/100 = 15 mL. Therefore, the nurse should administer 15 mL at each dose. Choice B (10 mL) is incorrect as it does not reflect the correct calculation based on the medication concentration. Choices C (20 mL) and D (5 mL) are also incorrect as they do not accurately calculate the volume required for the prescribed dose.

2. During the assessment of a client who has suffered a stroke, what finding would indicate a complication?

• A. Difficulty swallowing
• B. A slight headache
• C. High blood pressure
• D. Muscle weakness on one side

Correct answer: A

Rationale: Difficulty swallowing (dysphagia) can indicate complications such as aspiration risk, which is common after a stroke due to impaired swallowing reflexes. It poses a serious threat to the client's respiratory system. Options B, C, and D are less likely to indicate immediate complications post-stroke. A slight headache is a common complaint and may not necessarily indicate a complication. High blood pressure is a known risk factor for strokes but may not be an immediate post-stroke complication unless it is severely elevated. Muscle weakness on one side is a common sign of stroke but may not directly indicate a new complication.

3. The nurse is with a client when the healthcare provider explains that the biopsy classifies the results as a T1N0M0 tumor. What response should the nurse provide first?

• A. The letters represent tumor size, node involvement, and metastasis in cancer staging.
• B. The letters stand for tumor size, node involvement, and metastasis.
• C. Let me explain the cancer staging to you.
• D. Would you like further clarification on the tumor staging?

Correct answer: B

Rationale: Choice B is the correct answer as it accurately explains that the letters T, N, and M in cancer staging represent tumor size, node involvement, and metastasis, respectively. Understanding this staging system helps the client comprehend the extent and severity of the disease. Choices A, C, and D are incorrect. Choice A has the correct information but is not the most precise response. Choice C is vague and does not directly address the client's need for clarification. Choice D offers further clarification without directly addressing the initial explanation provided by the healthcare provider.

4. A client with a diagnosis of diabetes mellitus is experiencing symptoms of hypoglycemia. What is the nurse's priority intervention?

• A. Administer glucagon intramuscularly.
• B. Provide a complex carbohydrate snack.
• C. Administer 50% dextrose intravenously.
• D. Give 15 grams of a fast-acting carbohydrate.

Correct answer: D

Rationale: The correct answer is to give 15 grams of a fast-acting carbohydrate as the priority intervention in a client experiencing hypoglycemia. This helps quickly raise the blood glucose level. Administering glucagon intramuscularly (Choice A) is typically reserved for severe hypoglycemia where the client is unable to take oral carbohydrates. Providing a complex carbohydrate snack (Choice B) is not the priority in an acute hypoglycemic episode where immediate action is needed. Administering 50% dextrose intravenously (Choice C) is more invasive and usually reserved for cases where the client is unable to take anything by mouth.

5. What is the most important aspect of colostomy care to teach the client?

• A. Change the colostomy bag daily
• B. Irrigate the colostomy daily
• C. Avoid high-fiber foods
• D. Assess the stoma for color and swelling

Correct answer: D

Rationale: The most crucial aspect of colostomy care to teach the client is to assess the stoma for color and swelling. This is essential to detect early signs of complications such as ischemia or infection. Changing the colostomy bag daily is important but not as critical as assessing the stoma for complications. Irrigating the colostomy daily is not a standard recommendation and should be performed based on healthcare provider's instructions. While avoiding high-fiber foods may be beneficial for some individuals with a colostomy, it is not the most important aspect of care compared to monitoring the stoma for complications.

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