Nursing Elites

1. A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take?

• A. Gently shake the container of medication prior to administration
• B. Transfer the medication to a medicine cup
• C. Place the client in a semi-Fowler’s position for medication administration
• D. Verify the dosage by measuring the liquid before administering it

Correct answer: A

Rationale: The correct action for the nurse to take is to gently shake the container of liquid medication before administration. Shaking the container ensures proper mixing of the medication, which is important to maintain uniformity of the dose. Transferring the medication to a medicine cup (choice B) may not be necessary for a small volume like 0.5 mL. Placing the client in a semi-Fowler's position (choice C) is not directly related to administering liquid medication orally. Verifying the dosage by measuring the liquid (choice D) is important but does not address the specific action needed to prepare the medication for administration.

2. What is the most important assessment for the LPN/LVN to perform on a client with a history of chronic obstructive pulmonary disease (COPD) receiving oxygen therapy at 2 liters per minute via nasal cannula?

• A. Assess the client's respiratory rate and effort.
• B. Measure the client's oxygen saturation level.
• C. Monitor the client's arterial blood gas levels.
• D. Check the client's blood pressure.

Correct answer: B

Rationale: Measuring the client's oxygen saturation level is the most important assessment in this scenario. Oxygen saturation level reflects how well the client is oxygenating, which is crucial in assessing the effectiveness of oxygen therapy for a client with COPD. Monitoring the respiratory rate and effort (Choice A) is important but assessing oxygenation with saturation levels takes precedence. While arterial blood gas levels (Choice C) provide comprehensive information, checking oxygen saturation is a quicker and more immediate way to assess oxygenation status. Checking blood pressure (Choice D) is not the priority when evaluating the effectiveness of oxygen therapy in COPD.

3. A client with a history of heart failure presents with increased shortness of breath and swelling in the legs. What is the most important assessment for the LPN/LVN to perform?

• A. Monitor the client's oxygen saturation level.
• B. Assess the client's apical pulse.
• C. Check for jugular vein distention.
• D. Measure the client's urine output.

Correct answer: C

Rationale: Checking for jugular vein distention is crucial in assessing fluid overload in clients with heart failure. Jugular vein distention indicates increased central venous pressure, which can be a sign of worsening heart failure. Monitoring oxygen saturation (Choice A) is important but may not provide immediate information on fluid status. Assessing the apical pulse (Choice B) is relevant for monitoring heart rate but may not directly indicate fluid overload. Measuring urine output (Choice D) is essential for assessing renal function and fluid balance but does not provide immediate information on fluid overload in this scenario.

4. A client with diabetes mellitus is being taught by a nurse about mixing regular and NPH insulin. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should roll the NPH vial between my hands before drawing it up.
• B. I should draw up the NPH insulin before the regular insulin.
• C. I should inject air into the vial of regular insulin first.
• D. I should wait 10 minutes after mixing the insulin to inject it.

Correct answer: A

Rationale: The correct answer is A. Rolling the NPH vial between the hands before drawing it up ensures proper mixing of the insulin. Choice B is incorrect because regular insulin should be drawn up first to avoid contamination. Choice C is incorrect as injecting air into the vial of regular insulin is not necessary. Choice D is incorrect as there is no need to wait 10 minutes after mixing the insulin before injecting it.

5. A nurse in a provider’s office is collecting data from the caregiver of a 12-month-old infant who asks if the child is old enough for toilet training. Following an educational session with the nurse, the client agrees to postpone toilet training until the child is older. Learning has occurred in which of the following domains?

• A. Cognitive
• B. Affective
• C. Psychomotor
• D. Kinesthetic

Correct answer: B

Rationale: The correct answer is B: Affective. The caregiver’s decision to postpone toilet training indicates a change in feelings or attitudes, which falls under the affective domain of learning. The affective domain relates to emotions, values, and attitudes. In this scenario, the caregiver's willingness to delay toilet training due to new information reflects a shift in attitude impacted by the educational session provided by the nurse. Choices A, C, and D are incorrect. The cognitive (choice A) domain involves intellectual skills and knowledge, the psychomotor (choice C) domain involves physical skills, and kinesthetic (choice D) is often used interchangeably with the psychomotor domain, which focuses on physical movement and coordination.

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