Nursing Elites

1. The practical nurse is preparing to administer a prescription for cefazolin (Kefzol) 600 mg IM every six hours. The available vial is labeled, 'Cefazolin (Kefzol) 1 gram,' and the instructions for reconstitution state, 'For IM use add 2 ml sterile water for injection. Total volume after reconstitution = 2.5 ml.' When reconstituted, how many milligrams are in each milliliter of solution?

• A. 400 mg/mL
• B. 500 mg/mL
• C. 450 mg/mL
• D. 350 mg/mL

Correct answer: A

Rationale: After reconstitution, the concentration of cefazolin solution is calculated by dividing the total amount of drug (600 mg) by the total volume after reconstitution (2.5 mL). This gives 600 mg / 2.5 mL = 240 mg/mL. However, the question asks for the concentration in each milliliter of solution after reconstitution, so we need to consider the final volume of 2.5 mL. Therefore, 240 mg/mL * 2.5 mL = 600 mg, which means each milliliter contains 240 mg of cefazolin. Therefore, after reconstitution, there are 400 mg of cefazolin in each milliliter of solution. Choices B, C, and D are incorrect as they do not accurately reflect the concentration after reconstitution.

2. The nurse is preparing to administer a subcutaneous injection of heparin. What is the correct angle of insertion?

• A. 15 degrees
• B. 30 degrees
• C. 45 degrees
• D. 90 degrees

Correct answer: C

Rationale: The correct angle of insertion for a subcutaneous injection, such as heparin, is 45 degrees. This angle is appropriate as it helps to ensure proper delivery of the medication into the subcutaneous tissue. Option A (15 degrees) is too shallow for a subcutaneous injection and may result in the medication being deposited into the muscle. Option B (30 degrees) is also too shallow for subcutaneous injections. Option D (90 degrees) is used for intramuscular injections, not subcutaneous injections.

3. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is experiencing shortness of breath. What is the priority nursing intervention?

• A. Administer bronchodilator therapy as prescribed.
• B. Inhale the medication slowly while pressing down on the inhaler.
• C. Position the client in a high-Fowler's position.
• D. Increase the oxygen flow rate.

Correct answer: C

Rationale: The priority nursing intervention for a client with COPD experiencing shortness of breath is to position the client in a high-Fowler's position. This position helps improve lung expansion and ease breathing by maximizing chest expansion and allowing for better airflow. While administering bronchodilator therapy is important, positioning the client for improved breathing takes priority. Inhaling the medication slowly and pressing down on the inhaler is a correct technique for inhaler use but not the priority intervention. Increasing the oxygen flow rate may be needed, but adjusting the client's position to a high-Fowler's position is the priority to address the shortness of breath in COPD.

4. The nurse is monitoring a client with an IV infusion in the left antecubital fossa. The site is warm, red, and without swelling. What conclusion should the nurse draw from these findings?

• A. The IV fluids are infusing into the subcutaneous tissues
• B. The infusion pump is functioning properly
• C. The insertion date should be verified and the IV discontinued
• D. The site is inflamed and should be reported

Correct answer: B

Rationale: The correct answer is B. Warmth and redness at the IV site without swelling indicate a localized reaction, which is common and does not necessarily indicate infiltration of IV fluids into the subcutaneous tissues. The absence of swelling suggests that the IV is correctly placed. Therefore, the nurse should conclude that the infusion pump is functioning properly. Choice A is incorrect as warmth and redness alone do not indicate subcutaneous infiltration. Choice C is incorrect as discontinuing the IV solely based on warmth and redness without swelling is not necessary. Choice D is incorrect as the absence of swelling signifies a localized reaction rather than inflammation requiring immediate reporting.

5. The nurse is providing preoperative teaching to a client who will undergo a thyroidectomy. What information should the nurse include about postoperative care?

• A. Importance of maintaining neck stability
• B. How to care for the surgical drain
• C. Pain management strategies
• D. All of the above

Correct answer: D

Rationale: Providing preoperative teaching for a client undergoing a thyroidectomy is essential to prepare them for postoperative care. Information about the importance of maintaining neck stability is crucial to prevent complications such as strain on the surgical site. Teaching the client how to care for the surgical drain is important to prevent infections, ensure proper wound healing, and aid in monitoring postoperative recovery. Pain management strategies are vital to ensure the client's comfort and promote optimal recovery. Including all these aspects in preoperative teaching ensures the client is well-prepared for comprehensive postoperative care. Therefore, the correct answer is D because all these elements are essential components of postoperative care for a client undergoing a thyroidectomy. Choices A, B, and C are all important aspects of postoperative care that the nurse should include in the preoperative teaching session.

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