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 nurse enters a client's room and sees smoke coming from the trash can. Which of the following actions should the nurse take first?

• A. Close the window
• B. Evacuate the room
• C. Call the fire department
• D. Attempt to extinguish the fire

Correct answer: B

Rationale: The correct answer is to evacuate the room first. In a fire situation, the priority is safety, following the RACE protocol: Rescue, Alarm, Contain, Extinguish. Evacuating the room ensures the safety of both the client and the nurse. Closing the window (Choice A) can wait until after evacuation when there is no immediate danger. Calling the fire department (Choice C) is important but comes after ensuring personal safety and evacuating. Attempting to extinguish the fire (Choice D) is not recommended as it can put the nurse and the client at risk; firefighting should be left to professionals.

3. A nurse is assessing a client for signs of allergic reaction. Which of the following should the nurse look for?

• A. Fever
• B. Rash
• C. Fatigue
• D. Increased appetite

Correct answer: B

Rationale: Correct! When assessing a client for signs of an allergic reaction, a nurse should look for a rash. A rash is a common manifestation of an allergic response, such as contact dermatitis or hives. It is important to recognize and assess rashes promptly as they can indicate an allergic reaction.\nOption A, fever, is not typically a primary sign of an allergic reaction but may occur in severe cases. Option C, fatigue, is a general symptom and not specific to allergic reactions. Option D, increased appetite, is not a common sign of an allergic reaction and is more likely related to other conditions or factors.

4. A nurse is assessing a client who has Clostridium difficile (C. diff) infection. Which infection control measure should the nurse implement?

• A. Wear a face shield when entering the room
• B. Place the client in a private room
• C. Place the client in a negative pressure room
• D. Use alcohol-based hand rub following client care

Correct answer: B

Rationale: The correct answer is to place the client in a private room. Clostridium difficile (C. diff) infection requires contact precautions, which include isolating the client in a private room to prevent the spread of infection to others. Wearing a face shield may be necessary in certain situations for protection but is not the primary measure for C. diff. Placing the client in a negative pressure room is not specifically indicated for C. diff unless the client has additional respiratory issues. Using alcohol-based hand rub following client care is not sufficient for C. diff control; thorough handwashing with soap and water is recommended due to the spore-forming nature of C. diff.

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.

Similar Questions