Nursing Elites

1. A nurse is planning to administer several medications to a client through an NG tube. Which actions should the nurse take?

• A. Dissolve crushed tablet medications in tap water
• B. Use 30-40 mL of sterile water for each medication
• C. Dissolve crushed tablet medications in sterile water
• D. Administer medications without dissolving

Correct answer: C

Rationale: The correct action for the nurse to take when administering medications through an NG tube is to dissolve crushed tablet medications in 15-30 mL of sterile water. This ensures proper delivery through the NG tube and reduces the risk of clogging. Choice A is incorrect because tap water may contain impurities that can cause complications. Choice B suggests using a higher volume of sterile water than necessary, which may lead to dilution of the medications. Choice D is incorrect as medications should be dissolved to prevent blockages in the NG tube.

2. A charge nurse is planning care for a group of patients on a med-surg unit. What task should the nurse delegate to an assistive personnel?

• A. Measure hourly urinary output for the postoperative patient.
• B. Administer medications to stable patients.
• C. Reinforce patient education.
• D. Initiate a care plan for a new patient.

Correct answer: A

Rationale: The correct answer is A because assistive personnel can be assigned to measure and document urinary output, a routine task within their scope of practice. Administering medications (choice B) requires a higher level of training and should be done by licensed nurses. Reinforcing patient education (choice C) involves providing information and ensuring patient understanding, which is typically done by licensed healthcare providers. Initiating a care plan (choice D) involves critical thinking and assessment skills, which are beyond the scope of practice for assistive personnel.

3. A nurse is caring for a client who has been experiencing repeated tonic-clonic seizures over the course of 30 min. After maintaining the client’s airway and turning the client on their side, which of the following medications should the nurse administer?

• A. Diazepam IV
• B. Lorazepam PO
• C. Diltiazem IV
• D. Clonazepam PO

Correct answer: A

Rationale: In the scenario of a client experiencing prolonged seizures, such as status epilepticus, the priority is to administer a benzodiazepine to stop the seizure activity. Diazepam is the medication of choice for this situation due to its rapid onset of action and effectiveness in terminating seizures quickly. Lorazepam, although another benzodiazepine, is typically given through routes other than oral (PO) administration in emergency situations. Diltiazem is a calcium channel blocker used for cardiac conditions, not for seizure management. Clonazepam is a benzodiazepine, but it is usually not the first choice in the acute management of status epilepticus.

4. A client has a new prescription for oxcarbazepine. Which of the following should the nurse monitor?

• A. Liver function
• B. Serum sodium levels
• C. Blood glucose
• D. Heart rate

Correct answer: B

Rationale: The correct answer is B: Serum sodium levels. Oxcarbazepine can lead to hyponatremia, making it crucial to monitor serum sodium levels. Monitoring liver function (choice A) is not typically associated with oxcarbazepine use. Blood glucose (choice C) monitoring is more relevant in medications affecting blood sugar levels. Heart rate (choice D) is not directly impacted by oxcarbazepine.

5. While reviewing the medical record of a client with unstable angina, which of the following findings should the nurse report to the provider?

• A. BP 106/62 mm Hg, Temp 38°C (100.4°F), HR 112/min, Resp rate 26/min, urine output 90 mL/hr
• B. Skin is cool and moist with pallor
• C. Bilateral breath sounds with crackles heard at bases of lungs
• D. Creatinine kinase 100 units/L, C-reactive protein 0.8 mg/dL, Myoglobin 88 mcg/L

Correct answer: A

Rationale: The correct answer is A. The nurse should report these vital signs to the provider immediately as they indicate increased temperature, tachycardia, and tachypnea, which are signs of possible infection or systemic inflammatory response. This could exacerbate the client's unstable angina and needs prompt evaluation. Choices B, C, and D are not as urgent as the vital signs in option A and do not directly indicate a worsening condition in the context of unstable angina.

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