Nursing Elites

1. How should Lasix be administered to prevent hypotension?

• A. By administering it over 1-2 minutes
• B. By hanging it IV piggyback
• C. With normal saline only
• D. By administering it through a venous access device

Correct answer: A

Rationale: Lasix should be administered over 1-2 minutes at approximately 1mL per minute to prevent hypotension. This slow administration helps to reduce the risk of adverse effects such as sudden drops in blood pressure. Choice B is incorrect because Lasix does not need to be hung IV piggyback, choice C is incorrect as Lasix administration does not require it to be mixed with normal saline only, and choice D is incorrect as Lasix does not have to be specifically administered through a venous access device (VAD) to prevent hypotension.

2. While assessing a client who is dying for signs of impending death, what should the nurse observe for?

• A. Elevated blood pressure
• B. Cheyne-Stokes respiration
• C. Elevated pulse rate
• D. Decreased temperature

Correct answer: B

Rationale: When assessing a client for signs of impending death, the nurse should observe for Cheyne-Stokes respiration. This pattern involves rhythmic waxing and waning of respirations from very deep breathing to very shallow breathing with periods of temporary apnea. It is often associated with cardiac failure and can be a significant indicator of impending death. Elevated blood pressure and pulse rate are not typical signs of impending death; in fact, they may indicate other conditions. A decreased temperature is also not a common sign of impending death, as temperature changes can vary among individuals and may not always correlate with the dying process.

3. What significant event occurs in the orientation phase of a nurse-client relationship?

• A. establishment of roles
• B. identification of transference phenomenon
• C. placement of the client within their family structure
• D. client agreement that the nurse has the authority in the relationship

Correct answer: B

Rationale: In the orientation phase of a nurse-client relationship, the significant event is the identification of transference phenomenon. Transference phenomena are intensified in relationships with authority figures like nurses and physicians. Positive transferences may include a desire for affection and dependency, while negative transferences may involve hostility and competitiveness. It is crucial to recognize and address these transferences before progress and positive changes can be made in the working stage. The other choices are incorrect; the establishment of roles may occur in the working phase, placing the client within their family structure is not a key event in the orientation phase, and client agreement on the nurse's authority is not the primary focus during this phase.

4. The physician has ordered a culture for the client with suspected gonorrhea. The nurse should obtain which type of culture?

• A. Blood
• B. Nasopharyngeal secretions
• C. Stool
• D. Genital secretions

Correct answer: D

Rationale: A culture for gonorrhea is taken from the genital secretions as gonorrhea primarily affects the genital area. The culture is incubated in a warm environment to promote the growth of Neisseria gonorrhoeae, the bacterium causing gonorrhea. Genital secretions provide a direct sample from the site of infection, increasing the accuracy of diagnosis. Choices A, B, and C are incorrect as they are not suitable specimens for diagnosing gonorrhea. Blood cultures are used to detect bloodstream infections, nasopharyngeal secretions are collected for respiratory infections, and stool cultures are done to identify gastrointestinal infections, none of which are related to gonorrhea.

5. To ensure safety while administering a nitroglycerine patch, what should the nurse do?

• A. Wear gloves
• B. Shave the area where the patch will be applied
• C. Wash the area thoroughly with soap and rinse with hot water
• D. Apply the patch to the buttocks

Correct answer: A

Rationale: To protect herself, the nurse should wear gloves when applying a nitroglycerine patch or cream. Answer B is incorrect because shaving the area where the patch will be applied might abrade the skin, increasing the risk of irritation. Answer C is incorrect because washing with hot water can vasodilate the skin, potentially increasing the absorption of nitroglycerine. Nitroglycerine patches should be applied to areas above the waist, making answer D incorrect as applying it to the buttocks is not recommended.

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