Nursing Elites

1. A client will require oxygen therapy at home. Which of the following statements should the nurse identify as an indication that the client understands how to manage this therapy at home?

• A. I'll make sure that, when my friend comes by, they smoke at least 6 feet away from my oxygen tank.
• B. I'll use a cotton blanket if I get chilly while I'm using my oxygen.
• C. I'll check the wires and cables on my oxygen equipment to make sure they are in good working order.
• D. I'll secure my oxygen tank in an upright position to prevent it from being knocked over.

Correct answer: C

Rationale: The correct answer is C. Ensuring the oxygen equipment's wires and cables are in good working order is crucial to prevent sparks in an oxygen-rich environment, which could lead to a fire. Choices A, B, and D are incorrect because smoking near an oxygen tank, using a cotton blanket near oxygen (as cotton is less likely to generate static electricity than wool), and laying the oxygen tank down on the floor pose significant safety risks and are not appropriate practices for managing oxygen therapy at home.

2. A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the LPN/LVN to implement?

• A. Contact the healthcare provider and complete a medication variance form.
• B. Administer the Levaquin at 1300 and resume the 0900 schedule the next morning.
• C. Notify the charge nurse and complete an incident report to explain the missed dose.
• D. Give the missed dose at 1300 and change the schedule to administer daily at 1300.

Correct answer: D

Rationale: The correct intervention is to give the missed dose at 1300 and adjust the schedule to administer daily at 1300. This approach ensures that the client receives the correct total daily dose of levofloxacin. Choice A is incorrect because contacting the healthcare provider and completing a medication variance form would not address the immediate need to administer the missed dose. Choice B is incorrect as administering the missed dose at 1300 and resuming the 0900 schedule the next morning would result in a missed dose for that day. Choice C is not the best course of action as notifying the charge nurse and completing an incident report should come after addressing the immediate need to administer the missed dose and adjusting the schedule for future doses.

3. What is the rate of delivery in mL/hr if a total volume of 750 mL is infused over a period of 7 hours?

• A. 107 mL/hr.
• B. 107 mL/hr.
• C. 107 mL/hr.
• D. 107 mL/hr.

Correct answer: A

Rationale: The correct rate of delivery is 107 mL/hr. To find the rate of delivery, divide the total volume by the total time: 750 mL / 7 hours = 107 mL/hr. Choice B, C, and D are incorrect as they do not match the correct calculation based on the total volume and time provided.

4. While measuring a client’s vital signs, the nurse notices an irregularity in the heart rate. Which nursing action is appropriate?

• A. Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart
• B. Measure the blood pressure
• C. Perform an ECG
• D. Recheck the heart rate after 5 minutes

Correct answer: A

Rationale: The appropriate nursing action when an irregularity in the heart rate is observed is to count the apical pulse rate for a full minute and describe the rhythm in the chart. This approach helps in obtaining an accurate assessment of the irregularities present. Measuring the blood pressure (Choice B) is important but not the immediate priority when an irregular heart rate is noted. Performing an ECG (Choice C) may be necessary but is a more advanced intervention that should follow the initial assessment. Rechecking the heart rate after 5 minutes (Choice D) may delay potential interventions for addressing the irregularity, making it less appropriate than the immediate assessment and documentation of the pulse rhythm.

5. The patient has been brought to the emergency department following a motor vehicle accident. The patient is unresponsive. The driver's license states that glasses are needed to operate a motor vehicle, but no glasses were brought in with the patient. Which action should the nurse take next?

• A. Stand to the side of the patient's eye and observe the cornea.
• B. Conclude that the glasses were lost during the accident.
• C. Notify the ambulance personnel about the missing glasses.
• D. Ask the patient where the glasses are.

Correct answer: A

Rationale: In this scenario, the nurse should stand to the side of the patient's eye and observe the cornea. This action is crucial in assessing whether the patient wears contact lenses, especially in unresponsive patients. Observing the cornea can provide valuable information about the patient's eye health and potential use of contact lenses. Choices B, C, and D are incorrect. Concluding that the glasses were lost during the accident is premature without proper assessment. Notifying ambulance personnel about the missing glasses may not be the immediate priority, and asking the unresponsive patient about the glasses would not yield useful information in this situation.

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