Nursing Elites

1. The nurse needs to add a medication to a liter of 5% Dextrose in Water (D5W) that is already infusing into a client. At what location should the nurse inject the medication?

• A. Medication port
• B. IV drip chamber
• C. Y-site connector
• D. At the hub of the IV catheter

Correct answer: A

Rationale: The correct answer is the medication port. When adding medication to an already infusing IV solution, it should be done through the medication port to ensure direct delivery into the bloodstream without interrupting the primary IV line. Injecting the medication into the IV drip chamber, Y-site connector, or at the hub of the IV catheter can lead to dilution, inaccurate dosing, or potential blockages in the IV line, which can compromise the effectiveness of the medication and patient safety.

2. A client with cirrhosis is admitted with ascites and jaundice. Which assessment finding is most concerning?

• A. Peripheral edema
• B. Confusion and altered mental status
• C. Increased abdominal girth
• D. Yellowing of the skin

Correct answer: B

Rationale: Confusion and altered mental status are concerning signs of hepatic encephalopathy in a client with cirrhosis. Hepatic encephalopathy is a serious complication of liver disease that requires immediate intervention. Peripheral edema may be present due to fluid accumulation, increased abdominal girth can indicate ascites which is common in cirrhosis, and yellowing of the skin is a typical manifestation of jaundice in liver dysfunction, all of which are important but not as immediately concerning as signs of hepatic encephalopathy.

3. Progressive kyphoscoliosis leading to respiratory distress is evident in a client with muscular dystrophy. Which finding warrants immediate intervention by the nurse?

• A. Extremity muscle weakness.
• B. Bilateral eyelid drooping.
• C. Inability to swallow pills.
• D. Evidence of hypoventilation.

Correct answer: D

Rationale: The correct answer is D: Evidence of hypoventilation. In a client with muscular dystrophy and progressive kyphoscoliosis, hypoventilation indicates respiratory muscle weakness and can lead to life-threatening respiratory distress. Immediate intervention is crucial to prevent complications. Choices A, B, and C are incorrect because while extremity muscle weakness, bilateral eyelid drooping, and inability to swallow pills are concerning symptoms in muscular dystrophy, evidence of hypoventilation poses a more immediate threat to the client's respiratory status.

4. A client with a history of myocardial infarction is experiencing chest pain. Which intervention should the nurse implement first?

• A. Administer oxygen therapy as prescribed.
• B. Administer aspirin as prescribed.
• C. Administer nitroglycerin sublingually as prescribed.
• D. Obtain an electrocardiogram (ECG).

Correct answer: A

Rationale: Administering oxygen therapy is the initial priority in managing chest pain in a client with a history of myocardial infarction. Oxygen therapy helps improve oxygenation, which is crucial in reducing myocardial damage. While administering aspirin and nitroglycerin are essential interventions in the treatment of myocardial infarction, oxygen therapy takes precedence because it addresses the immediate need for oxygen supply to the heart muscle. Obtaining an ECG is important but can be done after ensuring adequate oxygenation.

5. While assisting a male client with muscular dystrophy (MD) to the bathroom, the nurse observes that he is awkward and clumsy. When he expresses his frustration and complains of hip discomfort, which intervention should the nurse implement?

• A. Place a portable toilet next to the bed.
• B. Assist the client with walking exercises.
• C. Provide pain medication as prescribed.
• D. Apply a heating pad to the affected hip.

Correct answer: A

Rationale: Placing a portable toilet next to the bed is the most appropriate intervention in this situation. It reduces the need for the client to walk long distances, thereby preventing falls and reducing discomfort. Choice B, assisting with walking exercises, would not be suitable for a client with muscular dystrophy who is experiencing awkwardness and clumsiness. Choice C, providing pain medication, may address the symptom but does not directly address the issue of reducing the need for walking. Choice D, applying a heating pad, may provide temporary relief but does not address the underlying issue of mobility and fall prevention.

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