Nursing Elites

1. The nurse is preparing to administer an oral antibiotic to a client with unilateral weakness, ptosis, mouth drooping, and aspiration pneumonia. What is the priority nursing assessment that should be done before administering this medication?

• A. Ask the client about soft food preferences
• B. Auscultate the client’s breath sounds
• C. Obtain and record the client’s vital signs
• D. Determine which side of the body is weak

Correct answer: B

Rationale: The correct answer is to auscultate the client’s breath sounds. Assessing breath sounds is crucial in this scenario as it helps ensure that the client can safely swallow the oral antibiotic without aspirating. Unilateral weakness, ptosis, mouth drooping, and aspiration pneumonia indicate potential swallowing difficulties, making it essential to assess breath sounds for any signs of respiratory issues. Asking about food preferences (choice A) may be relevant later but is not the priority before administering the medication. While obtaining vital signs (choice C) is important, assessing breath sounds takes precedence in this case. Determining which side of the body is weak (choice D) is not the priority assessment before administering the oral antibiotic.

2. A 10-year-old who has terminal brain cancer asks the nurse, 'What will happen to my body when I die?' How should the nurse respond?

• A. The heart will stop beating, and you will stop breathing.
• B. You will go to sleep and not wake up.
• C. Your body will stop functioning, and you will no longer feel pain.
• D. You will feel very tired, and your body will shut down slowly.

Correct answer: C

Rationale: The correct answer is C because it provides a truthful yet sensitive response to the child's question. Saying that the body will stop functioning and that there will be no more pain helps the child understand what to expect without unnecessary details or causing distress. Choice A is too technical and may not be suitable for a child. Choice B might give the impression of a peaceful passing, which may not always be the case. Choice D introduces the concept of feeling tired, which might not be accurate or helpful in this context.

3. An 8-year-old child who weighs 60 pounds receives an order for Polycilin (Ampicillin) suspension 25 mg/kg/day divided into a dose every 8 hours. The medication is labeled '125 mg/5 ml'. How many ml should the nurse administer per dose every 8 hours?

• A. 5
• B. 10
• C. 15
• D. 20

Correct answer: A

Rationale: Calculate the daily dose first: 60 pounds x 25 mg/kg = 1500 mg/day. Divide by 3 doses = 500 mg/dose. Convert to mL: (500 mg / 125 mg) x 5 ml = 20 ml. However, the question asks for the dose per administration every 8 hours, which is 1/3 of the daily dose. So, the correct calculation should be (20 ml / 3) = 6.67 ml, which rounds to 5 ml. Therefore, the correct answer is 5 ml. Choice B (10 ml) is incorrect because it doesn't consider the frequency of dosing. Choice C (15 ml) is incorrect as it overestimates the dose. Choice D (20 ml) is incorrect as it represents the total daily dose, not the dose per administration every 8 hours.

4. The nurse plans to collect a 24-hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client?

• A. Urinate at the specified time, discard this urine, and collect all subsequent urine over the next 24 hours.
• B. Cleanse around the meatus, discard the first portion of voiding, and collect the rest in a sterile bottle.
• C. For the next 24 hours, notify the nurse when the bladder is full, and the nurse will collect catheterized specimens.
• D. Urinate immediately into a urinal, and the lab will collect the specimen every 6 hours for the next 24 hours.

Correct answer: A

Rationale: The correct instruction for the adult male client to follow when collecting a 24-hour urine specimen for a creatinine clearance test is to urinate at the specified time, discard this urine, and collect all subsequent urine over the next 24 hours. This method ensures proper collection for an accurate creatinine clearance measurement. Choice B is incorrect as it describes a different procedure for a clean-catch urine sample, not suitable for creatinine clearance. Choice C is incorrect as it suggests catheterization, which is not typically done for a creatinine clearance test, and it is not necessary for this procedure. Choice D is incorrect as it does not follow the standard procedure for a 24-hour urine collection for creatinine clearance; the urine should be collected continuously over 24 hours, not at specified intervals.

5. The unlicensed assistive personnel (UAP) reports that a client’s blood pressure cannot be measured because the client has casts on both arms and is unable to be turned to the prone position for blood pressure measurement in the legs. What action should the nurse implement?

• A. Advise the UAP to document the last blood pressure obtained on the client's graphic sheet
• B. Estimate the blood pressure by assessing the pulse volume of the client’s radial pulses
• C. Demonstrate how to palpate the popliteal pulse with the client supine and the knee flexed
• D. Document why the blood pressure cannot be accurately measured at the present time

Correct answer: D

Rationale: When a client cannot have their blood pressure measured due to specific circumstances such as casts on both arms, the nurse should document the reason why the blood pressure cannot be obtained accurately. This documentation is crucial for maintaining a clear record of the client's condition and for continuity of care. Advising the UAP to document the last blood pressure obtained (Choice A) does not address the current inability to measure the blood pressure. Estimating the blood pressure by assessing the pulse volume of radial pulses (Choice B) is not a reliable method for obtaining accurate blood pressure readings. Demonstrating how to palpate the popliteal pulse (Choice C) is irrelevant in this situation as it does not provide a solution for accurately measuring the blood pressure.

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