Nursing Elites

1. A clinic nurse prepares to administer an MMR (measles, mumps, rubella) vaccine to a child. How is this vaccine best administered?

• A. Intramuscularly in the deltoid muscle
• B. Subcutaneously in the gluteal muscle
• C. Subcutaneously in the outer aspect of the upper arm
• D. Intramuscularly in the anterolateral aspect of the thigh

Correct answer: C

Rationale: The MMR vaccine is best administered subcutaneously in the outer aspect of the upper arm. This route allows for proper absorption and efficacy of the vaccine while minimizing the risk of injury or discomfort to the child.

2. After administering acetylcysteine (Mucomyst), 20% solution diluted in 0.9% normal saline by nebulizer, the nurse should have which item available for potential use?

• A. Ambu bag
• B. Intubation tray
• C. Nasogastric tube
• D. Suction equipment

Correct answer: D

Rationale: Acetylcysteine is administered via inhalation as a mucolytic. It helps liquefy secretions, making it easier for the client to clear them. However, in some cases, the increased volume of liquefied secretions may be challenging for the client to manage, leading to the potential need for suction equipment to assist in clearing the airway. Therefore, the nurse should have suction equipment available after administering acetylcysteine to address any issues related to excessive secretions.

3. While assisting in caring for a pregnant client receiving intravenous magnesium sulfate for preeclampsia management, a nurse notes the client's absent deep tendon reflexes. What determination should the nurse make based on this data?

• A. The magnesium sulfate is effective.
• B. The infusion rate needs to be increased.
• C. The client is experiencing cerebral edema.
• D. The client is experiencing magnesium toxicity.

Correct answer: D

Rationale: When a pregnant client receiving intravenous magnesium sulfate for preeclampsia management exhibits absent deep tendon reflexes, this indicates magnesium toxicity. Magnesium toxicity can occur as a complication of magnesium sulfate therapy, leading to suppressed reflexes. It is crucial for the nurse to recognize this sign promptly and report it to prevent further complications or harm to the client.

4. A client is receiving meperidine (Demerol) for pain management. Which assessment finding requires immediate action?

• A. Constipation
• B. Drowsiness
• C. Respiratory rate of 10 breaths per minute
• D. Nausea

Correct answer: C

Rationale: A respiratory rate of 10 breaths per minute indicates respiratory depression, a severe side effect of meperidine (Demerol) that necessitates immediate intervention to prevent further complications. Constipation, drowsiness, and nausea are common but less urgent side effects that do not pose an immediate life-threatening risk. Respiratory depression can lead to respiratory arrest and must be addressed promptly to ensure the client's safety and well-being.

5. A client is receiving intravenous gentamicin (Garamycin). Which of the following findings should prompt the nurse to notify the healthcare provider immediately?

• A. Nausea
• B. Hearing loss
• C. Headache
• D. Diarrhea

Correct answer: B

Rationale: Gentamicin (Garamycin) is an aminoglycoside antibiotic known to cause ototoxicity, which can manifest as hearing loss. Hearing loss is a serious adverse effect that should be reported promptly to the healthcare provider to prevent further complications or adjust the treatment regimen. Nausea, headache, and diarrhea are common side effects of gentamicin but are not as severe or urgent as hearing loss in this context.

Similar Questions