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 recovering from an acute myocardial infarction. Which of the following interventions should the nurse include in the plan of care?

• A. Draw a troponin level every four hours
• B. Perform an EKG every 12 hours
• C. Plan for oxygen therapy with a rebreather mask
• D. Obtain a cardiac rehabilitation consult

Correct answer: D

Rationale: The correct answer is to obtain a cardiac rehabilitation consult. Cardiac rehabilitation is an essential part of the care plan for a client recovering from a myocardial infarction. It helps in improving recovery, enhancing quality of life, and reducing the risk of future cardiac events. Drawing troponin levels and performing EKGs are important for diagnosing and monitoring myocardial infarctions but are not interventions in the post-MI care plan. Oxygen therapy may be necessary based on the client's condition but is not specific to post-MI care.

3. A nurse is caring for a client with a stage 2 pressure ulcer. Define the characteristics of the ulcer.

• A. Intact skin with nonblanchable redness (Stage 1)
• B. Full-thickness tissue loss with subQ damage (Stage 3)
• C. Partial-thickness skin loss involving the epidermis and dermis
• D. Full-thickness tissue loss with damage to muscle or bone (Stage 4)

Correct answer: C

Rationale: The correct answer is C. Stage 2 ulcers involve partial-thickness skin loss with visible and superficial damage, which may appear as an abrasion, blister, or shallow crater. Choice A describes a Stage 1 pressure ulcer characterized by intact skin with nonblanchable redness. Choice B describes a Stage 3 pressure ulcer with full-thickness tissue loss and damage to the subcutaneous tissue. Choice D is indicative of a Stage 4 pressure ulcer, involving full-thickness tissue loss with damage extending to muscle or bone.

4. A home health nurse is carefully planning care for a client with Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?

• A. Place a daily calendar in the kitchen
• B. Replace buttoned clothing with zippered items
• C. Replace carpet with hardwood floors
• D. Create variation in the daily routine

Correct answer: A

Rationale: Placing a daily calendar in the kitchen is essential for clients with Alzheimer's disease as it helps in orienting them to time and day, providing structure, and minimizing confusion in their daily routine. This action supports cognitive function and independence. Choice B is incorrect as it does not directly address cognitive orientation. Choice C is not a priority in the care plan and may not significantly impact the client's daily functioning. Choice D, creating variation in the daily routine, can actually increase confusion and anxiety in clients with Alzheimer's disease who thrive on predictability and structure.

5. A nurse is caring for a client who is receiving IV diltiazem for atrial fibrillation. Which of the following findings is a contraindication to the administration of diltiazem?

• A. Hypotension
• B. Tachycardia
• C. Decreased level of consciousness
• D. History of diuretic use

Correct answer: A

Rationale: The correct answer is A: Hypotension. Diltiazem can cause further lowering of blood pressure, so it should not be administered if the client is already hypotensive. Monitoring blood pressure is crucial before giving diltiazem. Choice B, tachycardia, is not a contraindication for diltiazem use; in fact, diltiazem is used to slow down the heart rate. Choice C, decreased level of consciousness, may indicate other issues but is not a direct contraindication for diltiazem. Choice D, history of diuretic use, is not a contraindication by itself; however, caution should be exercised when diltiazem is given with diuretics due to potential interactions.

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