Nursing Elites

1. A nurse is preparing to administer enoxaparin to a client. Which of the following actions should the nurse plan to take?

• A. Aspirate for a blood return before depressing the plunger
• B. Insert the needle at a 45-degree angle
• C. Administer the medication 2.54 cm (1 in) from the umbilicus
• D. The nurse should not expel the air bubble in the prefilled syringe

Correct answer: D

Rationale: The correct action when administering enoxaparin is not to expel the air bubble in the prefilled syringe. Expelling the air bubble may lead to the loss of medication and result in an incomplete dose. Aspirating for a blood return (Choice A) is not necessary for subcutaneous injections like enoxaparin. Inserting the needle at a 45-degree angle (Choice B) is not specific to administering enoxaparin. Administering the medication 2.54 cm (1 in) from the umbilicus (Choice C) is not a standard guideline for enoxaparin administration.

2. How should a healthcare provider respond to a patient who is exhibiting signs of acute myocardial infarction (AMI)?

• A. Calling for emergency assistance immediately
• B. Administering nitroglycerin as prescribed
• C. Monitoring the patient's cardiac rhythm
• D. Administering oxygen and preparing for ECG

Correct answer: A

Rationale: When a patient is exhibiting signs of acute myocardial infarction (AMI), the priority action is to call for emergency assistance immediately. This ensures that the patient receives prompt and appropriate care, including interventions such as administering oxygen, nitroglycerin, and monitoring cardiac rhythm. Administering nitroglycerin should only be done if prescribed by a healthcare provider after assessment and confirmation of AMI. Monitoring the patient's cardiac rhythm is important but not the initial action needed in this critical situation. Administering oxygen and preparing for an ECG are important interventions but should follow the immediate step of calling for emergency assistance.

3. A nurse at a local health department is caring for a client who is newly diagnosed with listeriosis. Which of the following actions should the nurse plan to take?

• A. Provide the Centers for Disease Control (CDC) and Prevention with the client's information
• B. Inform the client that they are required to have health department staff directly observe their treatment
• C. Determine whether the condition is reportable under state requirements
• D. Find out whether the condition is endemic in the client's neighborhood

Correct answer: C

Rationale: The correct answer is C: 'Determine whether the condition is reportable under state requirements.' Listeriosis is a reportable disease, meaning healthcare providers are legally required to report cases to public health authorities. By checking the state requirements for reportable diseases, the nurse ensures compliance with public health regulations. Choice A is incorrect because providing the client's information to the CDC is not the immediate action needed. Choice B is incorrect as direct observation of treatment is not a standard procedure for listeriosis. Choice D is also incorrect as determining if the condition is endemic in the client's neighborhood is not the primary concern when managing a diagnosed case of listeriosis.

4. A nurse is assessing a client who is receiving a continuous IV infusion of heparin. Which of the following findings should the nurse report to the provider?

• A. Report any urine output greater than 30 mL/hr.
• B. Bruising on the arms and legs.
• C. Positive Trousseau's sign.
• D. Urine output of 60 mL/hr.

Correct answer: B

Rationale: The correct answer is B. Bruising on the arms and legs is a sign of bleeding, which is a serious complication of heparin therapy and should be reported immediately to the provider. Option A is incorrect as urine output greater than 30 mL/hr is a normal finding. Option C, positive Trousseau's sign, is associated with hypocalcemia, not heparin therapy. Option D, urine output of 60 mL/hr, is within the normal range and does not indicate a complication of heparin therapy.

5. A nurse is teaching a client about levothyroxine for primary hypothyroidism. Which of the following statements should the nurse use when teaching the client?

• A. Take this medication until your symptoms are gone and then discontinue
• B. Symptoms improve immediately after starting the medication
• C. The medication decreases the overproduction of the thyroid hormone thyroxine
• D. Tremors, nervousness, and insomnia may indicate your dose is too high

Correct answer: D

Rationale: Tremors, nervousness, and insomnia indicate that the dose may be too high, requiring a dose adjustment.

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