Nursing Elites

1. The healthcare provider plans to administer diazepam, 4 mg IV push, to a client with severe anxiety. How many milliliters should the healthcare provider administer? (Round to the nearest tenth.)

• A. 0.2 mL
• B. 0.8 mL
• C. 1.25 mL
• D. 2.0 mL

Correct answer: B

Rationale: To calculate the volume to administer, use the formula (1 mL × 4 mg) / 5 mg = 0.8 mL. The healthcare provider should administer 0.8 mL of diazepam for a dosage of 4 mg IV push. Choice A is incorrect because it results from an incorrect calculation. Choices C and D are incorrect as they do not align with the correct calculation based on the provided dosage.

2. When caring for a client with a chest tube, which intervention is most important?

• A. Keep the drainage system at chest level.
• B. Ensure that the chest tube is clamped at all times.
• C. Strip the chest tube every shift.
• D. Ensure that the chest tube is connected to a water-seal drainage system.

Correct answer: D

Rationale: The most crucial intervention when caring for a client with a chest tube is to ensure that the chest tube is connected to a water-seal drainage system (D). This system helps maintain proper lung expansion and prevents complications. Keeping the drainage system at chest level (A) is important to facilitate drainage, but not as critical as ensuring the connection to the drainage system. Clamping the chest tube (B) is unnecessary and can lead to serious issues. Stripping the chest tube (C) is an outdated practice and can cause harm rather than benefit.

3. When assisting an older client who can stand but not ambulate from the bed to a chair, what is the best action for the nurse to implement?

• A. Use a mechanical lift to transfer the client from the bed to a chair.
• B. Place a roller board under the client who is sitting on the side of the bed and slide the client to the chair.
• C. Lift the client out of bed to the chair with another staff member using a coordinated effort on the count of three.
• D. Place a transfer belt around the client, assist the client to stand, and pivot to a chair that is placed at a right angle to the bed.

Correct answer: D

Rationale: The best action for the nurse when assisting an older client who can stand but not ambulate from the bed to a chair is to use a transfer belt. Placing a transfer belt around the client, assisting the client to stand, and pivoting to a chair that is placed at a right angle to the bed allows for a safe and controlled transfer. This method promotes patient independence while ensuring safety during the transfer process. Choices A, B, and C are incorrect because using a mechanical lift may not be necessary for a client who can stand, using a roller board may not provide enough stability, and lifting the client with the help of another staff member may not be the safest option for the client's independence and safety.

4. The client is being taught how to perform active range of motion (ROM) exercises. To exercise the hinge joints, which action should the client be instructed to perform?

• A. Tilt the pelvis forwards and backwards
• B. Bend the arm by flexing the ulnar to the humerus
• C. Turn the head to the right and left
• D. Extend the arm at the side and rotate it in circles

Correct answer: B

Rationale: Hinge joints, like the elbow, primarily allow movement in one direction, in this case, bending the arm. The correct action to exercise hinge joints is to bend the arm by flexing the ulnar to the humerus. This movement specifically targets the hinge joint and promotes its range of motion. Choices A, C, and D involve movements that do not specifically target hinge joints. Tilt the pelvis involves the ball-and-socket joints of the hip, turning the head involves the pivot joint of the neck, and extending the arm and rotating it in circles involve multiple joints including ball-and-socket and pivot joints.

5. What instruction should be provided for a UAP caring for a client with MRSA who has an order for contact precautions?

• A. Do not allow visitors until precautions are discontinued
• B. Wear sterile gloves when handling the client’s body fluids
• C. Have the client wear a mask whenever someone enters the room
• D. Don a gown and gloves when entering the room

Correct answer: D

Rationale: The correct instruction for a UAP caring for a client with MRSA under contact precautions is to don a gown and gloves when entering the client's room. This precaution is essential to prevent the spread of MRSA and protect both the client and the healthcare worker from potential infection. Choice A is incorrect because visitors should not be restricted solely based on contact precautions. Choice B is incorrect as wearing sterile gloves is not necessary, standard precautions with regular gloves are sufficient. Choice C is incorrect because the client wearing a mask is not a standard practice for contact precautions; it is the healthcare worker who should take preventive measures.

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