Nursing Elites

1. A nurse is caring for a patient with heart failure who has developed pulmonary edema. What is the nurse's priority action?

• A. Administer a diuretic as prescribed.
• B. Place the patient in a high Fowler's position.
• C. Administer oxygen via nasal cannula.
• D. Monitor the patient's lung sounds every 2 hours.

Correct answer: B

Rationale: The correct answer is to place the patient in a high Fowler's position. This position helps improve lung expansion and oxygenation in cases of pulmonary edema by reducing venous return to the heart and enhancing respiratory mechanics. Administering a diuretic (Choice A) can be important but is not the priority over positioning in this situation. Administering oxygen (Choice C) is essential, but the priority action for improving oxygenation is the positioning of the patient. Monitoring lung sounds (Choice D) is crucial for ongoing assessment but is not the priority action when the patient is in distress with pulmonary edema.

2. A nurse is providing teaching to the parent of a child who is receiving oral nystatin for oral candidiasis. Which of the following statements by the parent indicates an understanding of the teaching?

• A. I will mix the medication with applesauce
• B. I will provide a snack with the medication
• C. I will store the medication in the refrigerator
• D. I will swab the inside of my child's mouth with the medication

Correct answer: D

Rationale: The correct answer is D because swabbing the inside of the child's mouth with the nystatin solution is the correct administration method for treating oral candidiasis. Mixing the medication with applesauce or providing a snack with it is not the recommended method of administration. Storing the medication in the refrigerator is also unnecessary and not part of the proper administration instructions.

3. What is the most appropriate action for handling hazardous drugs?

• A. Wear gloves and wash hands after handling.
• B. Store the drugs according to manufacturer instructions.
• C. Discard unused drugs in regular trash.
• D. Wear personal protective equipment (PPE) when handling hazardous drugs.

Correct answer: D

Rationale: The most appropriate action when handling hazardous drugs is to wear personal protective equipment (PPE) to protect oneself from exposure to the harmful substances. Gloves and handwashing are important but may not provide sufficient protection from hazardous drugs. Storing drugs correctly and disposing of unused drugs properly are also essential, but the primary focus should be on using PPE to prevent exposure.

4. A client is prescribed 1g of potassium phosphate IV to be infused continuously over 6 hr. Available is 1 g in 250 ml of dextrose 5%. What rate should the nurse set the IV pump to run at?

• A. 40 ml/hr
• B. 42 ml/hr
• C. 44 ml/hr
• D. 46 ml/hr

Correct answer: B

Rationale: To calculate the IV rate, divide the total volume by the total time in hours. In this case, 1 g in 250 ml is to be infused over 6 hours. Therefore, 250 ml / 6 hr = 42 ml/hr. This means the IV pump should be set to run at 42 ml/hr. Choices A, C, and D are incorrect as they do not accurately calculate the infusion rate based on the provided information.

5. A patient is admitted and is placed on fall precautions. The nurse teaches the patient and family about fall precautions. Which action will the nurse take in accordance with hospital policy?

• A. Encourage visitors during visiting hours.
• B. Keep the patient on fall precautions until discharge.
• C. Check on the patient every shift.
• D. Raise all four side rails.

Correct answer: B

Rationale: The correct answer is B because patients on fall precautions need continuous monitoring until discharge to prevent falls. While encouraging visitors during visiting hours (Choice A) is important for the patient's well-being, it is not related to fall precautions. Checking on the patient every shift (Choice C) is an essential nursing intervention, but keeping the patient on fall precautions is more specific to preventing falls. Raising all four side rails (Choice D) is not recommended as it can restrict the patient's mobility and is considered a restraint practice.

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