Nursing Elites

1. A woman at 24-weeks gestation who has fever, body aches, and has been coughing for the last 5 days is sent to the hospital with admission prescriptions for H1N1 influenza. Which action has the highest priority?

• A. Administer Ringer's Lactate IV 125ml/8 hours
• B. Obtain specimens for cultures
• C. Assign a private room
• D. Monitor vital signs q4 hours

Correct answer: C

Rationale: Assigning a private room has the highest priority in this scenario. It helps prevent the spread of H1N1 influenza to other patients and protects both the patient and others from potential infection. Obtaining specimens for cultures and monitoring vital signs are important but do not address the immediate need to prevent the spread of the virus. Administering Ringer's Lactate IV is not the priority in this case as it does not directly address the infectious nature of the condition.

2. When caring for a laboring client whose contractions are occurring every 2 to 3 minutes, the nurse should document that the pump is infusing how many ml/hour? (Enter numeric value only. If rounding is required, round to the nearest whole number. Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client’s medical record.)

• A. 42
• B. 38
• C. 48
• D. 50

Correct answer: A

Rationale: By calculating the infusion rate based on the given chart information, the correct value is 42 ml/hr. This rate ensures proper fluid administration to the laboring client. Choices B (38), C (48), and D (50) are incorrect as they do not align with the calculated infusion rate needed for the client's condition, as per the chart data provided.

3. After the diagnosis and initial treatment of a 3-year-old with Cystic fibrosis, the nurse provides home care instructions to the mother. Which statement by the child's mother indicates that she understands home care treatment to promote pulmonary functions?

• A. Chest physiotherapy should be performed twice a day before a meal
• B. Energy should be conserved by scheduling minimally strenuous activities
• C. Administer a cough suppressant every 8 hours
• D. Maintain supplemental oxygen at 4 to 6 L/minute

Correct answer: A

Rationale: The correct answer is A. Chest physiotherapy is essential for maintaining pulmonary function in cystic fibrosis. It should be performed regularly, often twice daily, to clear mucus from the lungs. Choice B is incorrect because conserving energy does not directly promote pulmonary function. Choice C is incorrect as cough suppressants are not typically used to promote pulmonary function in cystic fibrosis. Choice D is incorrect as maintaining supplemental oxygen at 4 to 6 L/minute is not a standard home care treatment for promoting pulmonary functions in cystic fibrosis.

4. In developing a plan of care for a client admitted to a mental health unit after attempting suicide by taking a handful of medications, which goal has the highest priority?

• A. Signs a no-self-harm contract
• B. Sleep for at least 6 hours nightly
• C. Attends group therapy every day
• D. Verbalizes a positive self-image

Correct answer: A

Rationale: The correct answer is A: Signs a no-self-harm contract. Ensuring the client’s immediate safety by having them commit to not engaging in self-harm is the highest priority after a suicide attempt. This measure aims to prevent further harm to the client. While sleep, group therapy, and self-image are important aspects of care, they are secondary to ensuring the client's safety in the immediate aftermath of a suicide attempt. Prioritizing the establishment of a no-self-harm contract creates a foundation for addressing other therapeutic goals in the client's care plan.

5. A client is admitted to a medical unit with the diagnosis of gastritis and chronic heavy alcohol abuse. What should the nurse administer to prevent the development of Wernicke's syndrome?

• A. Lorazepam (Ativan)
• B. Famotidine (Pepcid)
• C. Thiamine (Vitamin B1)
• D. Atenolol (Tenormin)

Correct answer: C

Rationale: Thiamine supplementation is critical in preventing Wernicke's syndrome, especially in clients with chronic alcohol use. Wernicke's syndrome is a neurological disorder caused by thiamine deficiency. Lorazepam is a benzodiazepine used for anxiety and not for preventing Wernicke's syndrome. Famotidine is an H2 blocker used to reduce stomach acid production but does not prevent Wernicke's syndrome. Atenolol is a beta-blocker used for hypertension and angina, not for preventing Wernicke's syndrome.

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