Nursing Elites

1. A nurse is collecting data from a client who has Tourette syndrome. The client reports taking haloperidol 0.5 mL orally three times a day at home. Which of the following components of the prescription should the nurse question?

• A. Frequency
• B. Dosage
• C. Timing of doses
• D. Route

Correct answer: B

Rationale: The nurse should question the dosage of haloperidol as it is typically administered in milligrams (mg) and not milliliters (mL). The dosage should be expressed in a standardized unit for accuracy and to prevent medication errors. Frequency, timing of doses, and route are also important components of a prescription, but in this case, the nurse should focus on the unusual dosage form.

2. A client has an NG tube that needs to be irrigated every 8 hours. Which solution should the nurse use to maintain fluid and electrolyte balance?

• A. Tap water
• B. Sterile water
• C. 0.9% sodium chloride
• D. 0.45% sodium chloride

Correct answer: C

Rationale: The correct solution to maintain fluid and electrolyte balance during NG tube irrigation is 0.9% sodium chloride. This solution is isotonic and helps prevent electrolyte imbalances. Using tap water or sterile water can lead to electrolyte disturbances due to their hypotonic nature, while 0.45% sodium chloride is hypotonic and may cause further imbalances in the client's electrolyte levels.

3. What are the key interventions for managing pneumonia?

• A. Administer antibiotics and monitor oxygen levels
• B. Administer bronchodilators and encourage deep breathing
• C. Provide fluids and monitor for dehydration
• D. Administer oxygen and provide bed rest

Correct answer: A

Rationale: The correct answer is A: Administer antibiotics and monitor oxygen levels. Antibiotics are essential to treat the infection caused by bacteria in pneumonia, while monitoring oxygen levels helps ensure adequate oxygenation. Administering bronchodilators and encouraging deep breathing, as in choice B, are more commonly associated with managing conditions like asthma or COPD, not pneumonia. Providing fluids and monitoring for dehydration, as in choice C, are important for various conditions but not specific to pneumonia management. Administering oxygen and providing bed rest, as in choice D, may be supportive measures in pneumonia treatment, but the key intervention is administering antibiotics.

4. A nurse is reviewing the medical record of a client who is receiving warfarin for atrial fibrillation. Which of the following findings should the nurse report to the provider?

• A. International normalized ratio (INR) of 2.5
• B. Platelet count of 180,000/mm³
• C. Prothrombin time (PT) of 12 seconds
• D. Partial thromboplastin time (PTT) of 30 seconds

Correct answer: C

Rationale: A prothrombin time (PT) of 12 seconds is below the therapeutic range for warfarin and indicates a need for dosage adjustment. The correct answer is C. A normal International normalized ratio (INR) for a client on warfarin therapy is usually between 2.0 to 3.0; therefore, an INR of 2.5 is within the expected range. A platelet count of 180,000/mm³ is within the normal range (150,000 to 450,000/mm³) and does not require immediate reporting. A partial thromboplastin time (PTT) of 30 seconds is also within the normal range (25-35 seconds) and does not indicate a need for urgent action.

5. A client with diabetes mellitus is experiencing hypoglycemia. Which of the following actions should the nurse take?

• A. Administer insulin
• B. Administer glucagon
• C. Administer 4 oz of orange juice
• D. Administer 1 L of water

Correct answer: C

Rationale: Administering 4 oz of orange juice is the appropriate action for a client experiencing hypoglycemia due to diabetes mellitus. Orange juice contains simple sugars that can quickly raise blood glucose levels. Insulin (Choice A) would further lower blood sugar, worsening the condition. Glucagon (Choice B) is used in severe hypoglycemia when the client cannot take anything by mouth. Administering 1 L of water (Choice D) is not indicated in hypoglycemia treatment; the priority is to raise blood sugar levels. Therefore, the correct choice is to administer orange juice to address the low blood sugar in this situation.

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