Nursing Elites

1. The cognitive impairment is classified into four levels based on the intelligence quotient (IQ). How is a child with an IQ of 45 classified?

• A. Within the normal low range
• B. Educable
• C. Trainable
• D. Severe

Correct answer: C

Rationale: A child with an IQ of 45 is classified as 'Trainable' in the context of cognitive impairment levels. This category is determined by an IQ range of 35 to 55. Choice A ('Within the normal low range') is incorrect as an IQ of 45 falls within the range associated with the 'Trainable' level, not the 'Normal low range.' Choice B ('Educable') is incorrect because this classification typically corresponds to individuals with slightly higher IQs that allow for academic progress with support. Choice D ('Severe') is incorrect as it does not align with the IQ level of 45, which falls within the 'Trainable' category.

2. A client with diabetes mellitus presents with confusion and diaphoresis. What is the priority nursing action?

• A. Check the blood glucose level
• B. Administer insulin immediately
• C. Offer a high-protein snack
• D. Place the client in a supine position

Correct answer: A

Rationale: The correct answer is to check the blood glucose level. In a client with diabetes mellitus presenting with confusion and diaphoresis, it is important to assess the blood glucose level first to determine if the symptoms are due to hypoglycemia. Administering insulin immediately (Choice B) without knowing the blood glucose level can worsen the condition if the client is hypoglycemic. Offering a high-protein snack (Choice C) is not appropriate as the severity of hypoglycemia is unknown, and placing the client in a supine position (Choice D) is not the priority action for these symptoms.

3. The nurse is providing discharge teaching for a client with heart failure. Which instruction should be included to prevent fluid overload?

• A. Weigh yourself daily and report a gain of 2 pounds in 24 hours
• B. Increase fluid intake to stay hydrated
• C. Consume a high-sodium diet to retain fluids
• D. Engage in vigorous exercise daily

Correct answer: A

Rationale: The correct answer is A: 'Weigh yourself daily and report a gain of 2 pounds in 24 hours.' Daily weight monitoring is crucial for detecting fluid retention early in clients with heart failure. Reporting a gain of 2 pounds in 24 hours can indicate fluid overload, prompting timely intervention. Choice B is incorrect because increasing fluid intake can exacerbate fluid overload in clients with heart failure. Choice C is incorrect as a high-sodium diet can worsen fluid retention. Choice D is incorrect as vigorous exercise can strain the heart and worsen heart failure symptoms.

4. Before selecting which medication to administer, which action should the nurse implement if a postoperative client reports incisional pain and has two prescriptions for PRN analgesia?

• A. Compare the client’s pain scale rating with the prescribed dosing.
• B. Determine which prescription will have the quickest onset of action.
• C. Ask the client to choose which medication is needed for the pain.
• D. Document the client’s report of pain in the electronic medical record.

Correct answer: A

Rationale: When a postoperative client reports incisional pain and has two prescriptions for PRN analgesia, the nurse should first compare the client’s pain scale rating with the prescribed dosing. This action ensures that the client receives the appropriate medication based on their pain level. Determining the onset of action or asking the client to choose the medication does not guarantee that the right medication is administered according to the pain intensity. Documenting the pain report is important but should not be the first action when deciding which medication to administer.

5. A client is receiving a secondary infusion of erythromycin 1 gram in 100 mL dextrose 5% in water (D5W) to be infused in 45 minutes. How many mL/hour should the nurse program the infusion pump?

• A. 100 mL/hour.
• B. 125 mL/hour.
• C. 133 mL/hour.
• D. 150 mL/hour.

Correct answer: C

Rationale: To infuse 100 mL in 45 minutes, the infusion rate should be set to 133 mL/hour (100 mL / 0.75 hours). This calculation is obtained by dividing the total volume to be infused by the total time for infusion (100 mL / 0.75 hours = 133 mL/hour). Therefore, choice C is the correct answer. Choices A, B, and D are incorrect because they do not accurately calculate the infusion rate required to deliver the medication within the specified time frame.

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