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 client is receiving vancomycin. Which of the following should the nurse monitor?

• A. Blood glucose levels
• B. Serum creatinine
• C. INR levels
• D. Liver function tests

Correct answer: B

Rationale: The correct answer is B: Serum creatinine. Vancomycin is known to be nephrotoxic, meaning it can cause kidney damage. Monitoring serum creatinine levels is essential to assess kidney function and detect any signs of nephrotoxicity. Blood glucose levels (choice A) are not directly affected by vancomycin. INR levels (choice C) are typically monitored for clients on anticoagulants, not vancomycin. Liver function tests (choice D) are not primarily affected by vancomycin use; kidney function is of greater concern.

3. A nurse is planning care for a newly admitted adolescent client who has bacterial meningitis. Which of the following instructions is appropriate for the nurse to include in the plan of care?

• A. Initiate droplet precautions
• B. Assist the client to a supine position
• C. Perform Glasgow Coma Scale assessment every 24 hours
• D. Recommend prophylactic acyclovir for the client’s family

Correct answer: A

Rationale: The correct answer is A: 'Initiate droplet precautions.' Bacterial meningitis requires droplet precautions to prevent the spread of infection, as the bacteria can be transmitted through respiratory secretions. Choice B is incorrect because assisting the client to a supine position is not specific to the care of a client with bacterial meningitis and may not be appropriate for all clients. Choice C is incorrect because while performing Glasgow Coma Scale assessments is important in managing clients with neurological conditions, it is not directly related to preventing the spread of bacterial meningitis. Choice D is incorrect because recommending prophylactic acyclovir for the client's family is not a standard precautionary measure for preventing the spread of bacterial meningitis.

4. A nurse is assessing a client who has a sodium level of 122 mEq/L. Which of the following findings should the nurse expect?

• A. Decreased deep tendon reflexes
• B. Positive Trousseau’s sign
• C. Hypoactive bowel sounds
• D. Sticky mucous membranes

Correct answer: A

Rationale: A sodium level of 122 mEq/L indicates hyponatremia, which is characterized by decreased deep tendon reflexes. Hyponatremia leads to neurological symptoms such as altered reflexes. Choices B, C, and D are not typically associated with hyponatremia. Positive Trousseau’s sign is related to hypocalcemia, hypoactive bowel sounds can be seen in paralytic ileus or decreased peristalsis, and sticky mucous membranes are not specific findings related to sodium imbalances.

5. A client is being treated for eclampsia. What is a priority nursing intervention?

• A. Assess for hyperreflexia
• B. Administer oxygen
• C. Monitor blood pressure every 15 minutes
• D. Prepare for delivery

Correct answer: A

Rationale: The correct answer is to 'Assess for hyperreflexia.' Eclampsia is a severe complication of pregnancy that involves seizures. Hyperreflexia, an overactive or overresponsive reflex, is often an early sign of impending eclampsia. By assessing for hyperreflexia, nurses can identify this warning sign and take preventive measures to manage the condition before seizures occur. Administering oxygen (Choice B) may be necessary but is not the priority in this situation. Monitoring blood pressure (Choice C) is important but assessing for hyperreflexia takes precedence as it can lead to immediate life-threatening complications. While preparing for delivery (Choice D) may ultimately be necessary, the immediate priority is to assess for hyperreflexia to prevent seizures.

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