Nursing Elites

1. A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar. Which of the following actions should the nurse take?

• A. Consult the medication reference book available on the unit.
• B. Administer the medication as ordered.
• C. Ask a colleague for information about the medication.
• D. Contact the provider to clarify the medication.

Correct answer: A

Rationale: When encountering an unfamiliar medication, the safest action for a nurse is to consult the medication reference book available on the unit. This resource provides accurate and detailed information about medications, including indications, dosages, side effects, and nursing considerations. Administering a medication without understanding it (choice B) can lead to medication errors and harm to the client. Asking a colleague for information (choice C) may not always provide accurate or up-to-date information. Contacting the provider (choice D) should be reserved for situations where immediate clarification is needed, but consulting the reference book is the initial step to gain knowledge and ensure safe medication administration.

2. The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in 8 mg per ml. How many ml should the LPN/LVN administer?

• A. 0.5 ml
• B. 1 ml
• C. 1.5 ml
• D. 2 ml

Correct answer: A

Rationale: To administer 4 mg of morphine, as prescribed, the LPN/LVN needs to calculate the correct volume based on the concentration provided (8 mg per ml). Since the desired dose is 4 mg, half of 8 mg (0.5 ml) is required to administer the correct amount. Therefore, the correct answer is 0.5 ml. Choices B, C, and D are incorrect as they would either underdose or overdose the patient.

3. A client who has had an allogeneic stem cell transplant needs protective measures. What precaution should the nurse plan for this client?

• A. Ensure the client wears a mask when outside the room if there is construction nearby.
• B. Place the client in a private room with positive pressure airflow.
• C. Restrict all visitors from seeing the client.
• D. Provide a HEPA filter in the client's room.

Correct answer: A

Rationale: For a client who has undergone an allogeneic stem cell transplant, it is crucial to minimize exposure to potential sources of infection. Wearing a mask when outside the room, especially in areas with construction or other potential risks, helps protect the client's compromised immune system. Positive pressure airflow rooms are typically used for clients with airborne infections, not for those post-stem cell transplant. Restricting all visitors may contribute to the client's well-being, but it is not a direct protective measure against infection. While HEPA filters can be beneficial in maintaining air quality, wearing a mask when exposed to external risks is a more targeted and immediate protective measure in this scenario.

4. A cerebrovascular accident patient is placed on a ventilator. The client’s daughter arrives with a durable power of attorney and a living will that indicates no extraordinary life-saving measures. What action should the nurse take?

• A. Refer to the risk manager
• B. Notify the healthcare provider
• C. Discontinue the ventilator
• D. Review the medical record

Correct answer: B

Rationale: The correct action for the nurse to take is to notify the healthcare provider. In this situation, involving the healthcare provider ensures appropriate review and adherence to legal and ethical standards based on the living will and durable power of attorney. Referring to the risk manager may not be directly related to the immediate decision-making process regarding the ventilator. Discontinuing the ventilator without proper authorization from the healthcare provider could lead to legal and ethical implications. Reviewing the medical record alone may not provide guidance on how to proceed with the specific instructions from the living will and durable power of attorney.

5. The client with gastroesophageal reflux disease (GERD) is receiving dietary modification education from the nurse. Which statement by the client indicates a need for further teaching?

• A. I will avoid eating large meals before bedtime.
• B. I will limit coffee consumption to the morning hours.
• C. I will elevate the head of my bed while sleeping.
• D. I will avoid spicy and acidic foods.

Correct answer: B

Rationale: The correct answer is B. Clients with GERD should avoid coffee as it can relax the lower esophageal sphincter and exacerbate symptoms. Limiting coffee consumption to the morning hours may not be sufficient, as coffee can still contribute to GERD symptoms throughout the day. Choices A, C, and D are all appropriate strategies for managing GERD symptoms. Avoiding large meals before bedtime, elevating the head of the bed while sleeping, and steering clear of spicy and acidic foods are all recommended practices to help alleviate GERD symptoms. Therefore, the client's statement in option B indicates a need for further teaching to completely address dietary modifications for managing GERD.

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