Nursing Elites

1. The healthcare provider prescribes erythromycin (Ilosone) 300 mg PO QID. The medication label reads, 'Ilosone 100mg/5mL.' How many mL should the nurse administer at each dose?

• A. 15 mL
• B. 10 mL
• C. 20 mL
• D. 5 mL

Correct answer: A

Rationale: To determine the volume of medication needed for a 300 mg dose of Ilosone (100mg/5mL), we set up a proportion: 100 mg is to 5 mL as 300 mg is to x mL. Cross-multiplying, we get x = (300*5)/100 = 15 mL. Therefore, the nurse should administer 15 mL at each dose. Choice B (10 mL) is incorrect as it does not reflect the correct calculation based on the medication concentration. Choices C (20 mL) and D (5 mL) are also incorrect as they do not accurately calculate the volume required for the prescribed dose.

2. The nurse is assessing a client with chronic liver disease. Which lab value is most concerning?

• A. Elevated AST and ALT levels
• B. Decreased albumin level
• C. Elevated bilirubin level
• D. Prolonged PT/INR

Correct answer: D

Rationale: In a client with chronic liver disease, a prolonged PT/INR is the most concerning lab value. This finding indicates impaired liver function affecting the synthesis of clotting factors, leading to an increased risk of bleeding. Elevated AST and ALT levels (Choice A) indicate liver cell damage but do not directly correlate with the risk of bleeding. A decreased albumin level (Choice B) is common in liver disease but is not the most concerning in terms of bleeding risk. Elevated bilirubin levels (Choice C) are seen in liver disease but do not directly reflect the risk of bleeding as PT/INR values do.

3. The nurse is preparing to administer an intramuscular injection to a 6-month-old infant. Which site is most appropriate for this injection?

• A. Deltoid muscle
• B. Ventrogluteal muscle
• C. Dorsogluteal muscle
• D. Vastus lateralis muscle

Correct answer: D

Rationale: The vastus lateralis muscle is the preferred site for intramuscular injections in infants due to its size and safety. The deltoid muscle is typically used for adults and older children. The ventrogluteal muscle is more commonly used in toddlers and older children. The dorsogluteal muscle is not recommended for intramuscular injections in any age group due to its proximity to major nerves and blood vessels, which poses a risk of injury or sciatic nerve damage.

4. A client comes to the antepartal clinic and tells the nurse that she is 6 weeks pregnant. Which sign is she most likely to report?

• A. Decreased sexual libido
• B. Amenorrhea
• C. Quickening
• D. Nocturia

Correct answer: B

Rationale: Amenorrhea is the absence of menstrual periods and is a common early sign of pregnancy, typically reported by a client who is 6 weeks pregnant. Decreased sexual libido (Choice A) may or may not be experienced in early pregnancy, but it is not as specific as amenorrhea. Quickening (Choice C) refers to fetal movements felt by the mother, which usually occurs around 18-20 weeks of pregnancy, not at 6 weeks. Nocturia (Choice D) is waking up at night to urinate and is not typically associated with early pregnancy.

5. A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). Which nursing interventions should the nurse include in the plan of care? (Select all that apply.)

• A. Send wound drainage for culture and sensitivity.
• B. Institute contact precautions for staff and visitors.
• C. Use standard precautions and wear a mask.
• D. Monitor the client's white blood cell count.

Correct answer: B

Rationale: When dealing with a client suspected of having MRSA, the nurse should implement contact precautions to prevent the spread of infection. This includes using gowns and gloves, along with following proper hand hygiene practices. Sending wound drainage for culture and sensitivity may be necessary for diagnostic purposes, but it is not directly related to preventing the spread of infection in this case. Using standard precautions and wearing a mask are not sufficient when dealing with MRSA; contact precautions are specifically required to prevent transmission. Monitoring the client's white blood cell count is important in assessing infection status but is not a primary intervention to prevent the spread of MRSA.

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