Nursing Elites

1. The healthcare provider orders an IV solution of dextrose 5% in water at 100ml/hour. What would the flow rate be if the drop factor is 15 gtt = 1 ml?

• A. 5 gtt/minute
• B. 13 gtt/minute
• C. 25 gtt/minute
• D. 50 gtt/minute

Correct answer: C

Rationale: To determine the flow rate in drops per minute, multiply the ordered volume per hour by the drop factor (100 ml/hour x 15 gtt/ml = 1500 gtt/hour). Then, divide the result by 60 minutes to convert it to drops per minute (1500 gtt/hour ÷ 60 minutes = 25 gtt/minute). Therefore, the correct answer is 25 gtt/minute.

2. When planning care for a client with severe acute respiratory distress syndrome (SARS), which of the following actions should not be included in the care plan?

• A. Administer antibiotics
• B. Provide supplemental oxygen
• C. Administer antiviral medications
• D. Administer bronchodilators

Correct answer: A

Rationale: Severe acute respiratory distress syndrome (SARS) is caused by a virus, not bacteria, and antibiotics are ineffective against viral infections. Therefore, administering antibiotics would not be appropriate in the care plan for a client with SARS. The priority interventions for SARS include providing supplemental oxygen to improve oxygenation, administering antiviral medications to target the viral infection, and using bronchodilators to help with bronchospasm or airway constriction. Antibiotics are not indicated unless there is a secondary bacterial infection present.

3. A client had oral surgery following a motor vehicle accident. The nurse assessing the client finds the skin flushed and warm. Which of the following would be the best method to take the client’s body temperature?

• A. Oral
• B. Axillary
• C. Arterial line
• D. Rectal

Correct answer: D

Rationale: In cases where the oral route is contraindicated due to oral surgery or altered consciousness, the rectal method is preferred for the most accurate body temperature reading. This method is particularly useful when the skin is flushed and warm, as it provides a reliable reflection of core body temperature despite external factors affecting the skin temperature. Axillary temperature may not be as accurate as rectal temperature due to variations caused by environmental factors and technique. Arterial line temperature monitoring is invasive and not typically used for routine temperature assessment.

4. A client is being cared for by a nurse 2 hours after admission. The client has an SaO2 of 91%, exhibits audible wheezes, and is using accessory muscles when breathing. Which of the following classes of medication should the nurse expect to administer?

• A. Antibiotic
• B. Beta-blocker
• C. Antiviral
• D. Beta2 agonist

Correct answer: D

Rationale: The client's presentation with an SaO2 of 91%, audible wheezes, and use of accessory muscles indicates respiratory distress, likely due to bronchoconstriction. Beta2 agonists are the appropriate class of medications to administer in this situation as they act as bronchodilators, helping to relieve the bronchoconstriction and improve airflow to the lungs. Antibiotics, beta-blockers, and antivirals are not indicated for this client's respiratory distress symptoms.

5. A patient presents with an exacerbation of chronic obstructive pulmonary disease (COPD) characterized by shortness of breath, orthopnea, thick, tenacious secretions, and a dry hacking cough. An appropriate nursing diagnosis would be:

• A. Ineffective airway clearance related to thick, tenacious secretions.
• B. Ineffective airway clearance related to dry, hacking cough.
• C. Ineffective individual coping with COPD.
• D. Pain related to immobilization of affected leg.

Correct answer: A

Rationale: The patient's symptoms of shortness of breath, orthopnea, thick, tenacious secretions, and a dry hacking cough all point towards a potential airway clearance issue. This makes option A, 'Ineffective airway clearance related to thick, tenacious secretions,' the most appropriate nursing diagnosis. It directly addresses the thick secretions and suggests a potential cause of the breathing difficulty the patient is experiencing.

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