Nursing Elites

1. Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5.5 hours. How much heparin has the client received?

• A. 11,000 units.
• B. 13,000 units.
• C. 15,000 units.
• D. 17,000 units.

Correct answer: A

Rationale: To calculate the total amount of heparin received, multiply the infusion rate (50 ml/hour) by the total infusion time (5.5 hours). This results in 275 ml of the solution infused. Since there are 20,000 units of heparin in 500 ml, there are 800 units per ml. Therefore, 275 ml contains 220,000 units. However, the heparin is diluted in 500 ml, so the client has received half of this amount, which is 110,000 units. Therefore, the correct answer is 11,000 units. Choices B, C, and D are incorrect as they do not reflect the correct calculation based on the provided information.

2. A nurse is preparing to check a client's blood pressure. Which of the following actions should the nurse take?

• A. Apply the cuff above the client's antecubital fossa.
• B. Use a cuff with a width that is about 60% of the client's arm circumference.
• C. Have the client sit with their arm resting at the level of their heart.
• D. Release the pressure on the client's arm at a rate of 5 to 6 mm per second.

Correct answer: A

Rationale: The correct action when checking a client's blood pressure is to apply the cuff above the client's antecubital fossa. Placing the cuff above this area allows for an accurate measurement of blood pressure. Choice B is incorrect because the cuff width should be approximately 40% of the arm circumference, not 60%. Choice C is incorrect as the client's arm should rest at heart level, not above it, to ensure an accurate reading. Choice D is incorrect as the pressure on the client's arm should be released at a rate of 2 to 3 mm per second, not 5 to 6 mm per second.

3. While being educated by a nurse, an assistive personnel (AP) is learning about proper hand hygiene. Which statement made by the AP indicates a good understanding of the teaching?

• A. There are times I should use soap and water rather than alcohol-based hand rub to clean my hands.
• B. I can use alcohol-based hand rub after using the restroom.
• C. Soap and water are only necessary if my hands are visibly dirty.
• D. Hand rub is always sufficient, regardless of the situation.

Correct answer: C

Rationale: Choice C is the correct answer because it demonstrates an understanding that soap and water should be used when hands are visibly dirty or when dealing with specific pathogens. Choice A is incorrect because it suggests the use of soap and water over alcohol-based hand rub without specifying the circumstances. Choice B is incorrect as it implies that using alcohol-based hand rub after using the restroom is always suitable. Choice D is incorrect because it states that hand rub is always enough, which is not true when hands are visibly soiled or when specific pathogens are present.

4. A client has Clostridium difficile and is in contact isolation. Which of the following actions should the nurse take?

• A. Wear gloves when changing the client's gown.
• B. Use hand sanitizer after contact with the client.
• C. Wear a mask when entering the client's room.
• D. Clean the room with a disinfectant spray.

Correct answer: A

Rationale: The correct action for the nurse to take when caring for a client with Clostridium difficile in contact isolation is to wear gloves when changing the client's gown. Clostridium difficile is highly transmissible, and wearing gloves helps prevent the spread of the infection. Using hand sanitizer after contact with the client (Choice B) is not enough to prevent the transmission of C. difficile, as the spores can persist and spread. Wearing a mask when entering the client's room (Choice C) is not necessary for C. difficile transmission, which primarily occurs through contact with contaminated surfaces. Cleaning the room with a disinfectant spray (Choice D) is important, but wearing gloves during direct care is the priority to prevent the nurse from acquiring and spreading the infection.

5. A client with a history of coronary artery disease is experiencing chest pain. What is the priority action for the nurse to take?

• A. Administer oxygen via a nasal cannula.
• B. Measure the client's vital signs.
• C. Obtain a 12-lead ECG.
• D. Encourage the client to use pursed-lip breathing.

Correct answer: A

Rationale: Administering oxygen via a nasal cannula is the priority action for a client experiencing chest pain due to coronary artery disease. Oxygen therapy helps improve oxygenation, reduce myocardial workload, and relieve chest pain by increasing oxygen delivery to the heart muscle. While measuring vital signs, obtaining a 12-lead ECG, and encouraging pursed-lip breathing are important interventions, administering oxygen takes precedence in this situation to address the potential hypoxemia associated with chest pain in a client with a history of coronary artery disease.

Similar Questions