Nursing Elites

1. The patient will begin taking penicillin G procaine (Wycillin). The nurse notes that the solution is milky in color. What action will the nurse take?

• A. Call the pharmacist and report the milky color.
• B. Add normal saline to dilute the medication.
• C. Call the physician and report the milky appearance.
• D. Administer the medication as ordered by the physician.

Correct answer: D

Rationale: The correct answer is to administer the medication as ordered by the physician. Penicillin G procaine (Wycillin) is known to have a milky appearance, which is normal. The milky color should not raise concerns for the nurse as it is an expected characteristic of this medication. Calling the pharmacist (choice A) or the physician (choice C) unnecessarily would delay the administration of the medication. Adding normal saline to dilute the medication (choice B) is not appropriate and could alter the medication's effectiveness. Therefore, the nurse should proceed with administering the medication as prescribed without any further action based on its milky appearance.

2. A client has driven himself to the emergency department. He is 50 years old, has a history of hypertension, and informs the nurse that his father died from a heart attack at age 60. The client has indigestion. The nurse connects him to an electrocardiogram monitor and begins administering oxygen at 2 L/min via nasal cannula. What should the nurse do next?

• A. Call for the physician.
• B. Start an IV infusion.
• C. Obtain a portable chest radiograph.
• D. Draw blood for laboratory studies.

Correct answer: B

Rationale: In a client presenting with possible myocardial infarction who is receiving oxygen therapy and cardiac monitoring, the next priority action is to establish IV access by starting an IV infusion. This allows for prompt administration of medications and fluids as needed in the management of acute coronary syndromes. Calling the physician (Choice A) may be necessary but is not the immediate next step. Obtaining a portable chest radiograph (Choice C) may help in further assessment but is not as crucial as establishing IV access. Drawing blood for laboratory studies (Choice D) is important for diagnostic purposes but is not as urgent compared to starting an IV infusion in the setting of a potential myocardial infarction.

3. Which of the following medications is typically used to treat asthma?

• A. Aspirin
• B. Metformin
• C. Albuterol
• D. Lisinopril

Correct answer: C

Rationale: The correct answer is C, Albuterol. Albuterol is a bronchodilator commonly used to treat asthma by relaxing the muscles around the airways, helping to relieve symptoms such as coughing, wheezing, shortness of breath, and chest tightness. Aspirin (Choice A) is not typically used to treat asthma and can actually trigger asthma symptoms in some individuals. Metformin (Choice B) is a medication for managing type 2 diabetes and is not indicated for asthma treatment. Lisinopril (Choice D) is an angiotensin-converting enzyme (ACE) inhibitor primarily used to treat high blood pressure and heart failure, not asthma.

4. Laboratory findings indicate that a client's serum potassium level is 2.5 mEq/L. What action should the nurse take?

• A. Inform the healthcare provider of the need for potassium replacement.
• B. Prepare to administer a glucose-insulin-potassium replacement.
• C. Change the plan of care to include hourly urinary output measurement.
• D. Instruct the client to increase daily intake of potassium-rich foods.

Correct answer: A

Rationale: A serum potassium level of 2.5 mEq/L is critically low, indicating severe hypokalemia. The immediate action the nurse should take is to inform the healthcare provider of the need for potassium replacement. Option B, preparing to administer glucose-insulin-potassium replacement, is not the first-line intervention; it may be considered in specific situations but requires a healthcare provider's prescription. Option C, changing the plan of care to include hourly urinary output measurement, is not the priority when managing critically low potassium levels. Option D, instructing the client to increase daily intake of potassium-rich foods, is not appropriate in this acute situation where immediate intervention is needed to address the dangerously low potassium level.

5. A client has been scheduled for magnetic resonance imaging (MRI). For which of the following conditions, a contraindication to MRI, does the nurse check the client’s medical history?

• A. Pancreatitis
• B. Pacemaker insertion
• C. Type 1 diabetes mellitus
• D. Chronic airway limitation

Correct answer: B

Rationale: The correct answer is B: Pacemaker insertion. Patients with metal devices or implants are contraindicated for MRI. These include pacemakers, orthopedic hardware, artificial heart valves, aneurysm clips, and intrauterine devices. These metal objects can be affected by the strong magnetic field of the MRI, leading to serious risks for the patient. Pancreatitis (choice A), Type 1 diabetes mellitus (choice C), and chronic airway limitation (choice D) are not contraindications to MRI based on the presence of metal objects. Therefore, the nurse should be particularly concerned about pacemaker insertion when reviewing the client's medical history prior to an MRI.

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