Nursing Elites

1. Which intervention is most effective for managing a patient with constipation?

• A. Increase the patient's fluid intake.
• B. Administer a stool softener as prescribed.
• C. Provide the patient with a high-fiber diet.
• D. Teach the patient to perform Valsalva maneuvers.

Correct answer: B

Rationale: The most effective intervention for managing constipation in a patient is to administer a stool softener as prescribed. Stool softeners help relieve constipation by making the stool easier to pass, especially in postoperative patients. Increasing fluid intake can be beneficial but may not address the underlying cause of constipation. While a high-fiber diet is important for bowel health, it may not provide immediate relief for constipation. Teaching a patient to perform Valsalva maneuvers is not recommended for managing constipation as it can lead to adverse effects like increasing intra-abdominal pressure.

2. A nurse is preparing to administer ampicillin 500 mg IV bolus every 6 hours. Available is ampicillin 500 mg in 50 mL dextrose 5% in water (D5W) to infuse over 20 minutes. The nurse should set the IV pump to deliver how many mL/hr?

• A. 100 mL/hr
• B. 150 mL/hr
• C. 200 mL/hr
• D. 250 mL/hr

Correct answer: B

Rationale: To infuse 50 mL over 20 minutes, the pump should be set to 150 mL/hr. This calculation ensures the correct rate for the infusion of the medication. Choices A, C, and D are incorrect as they do not align with the correct calculation based on the given information.

3. If a nurse is uncomfortable documenting a verbal prescription, what should the nurse do?

• A. Document the prescription without seeking clarification.
• B. Clarify the verbal prescription with the healthcare provider.
• C. Refuse to document the prescription.
• D. Speak with the client's family to clarify the situation.

Correct answer: B

Rationale: When a nurse is uncomfortable documenting a verbal prescription, the best course of action is to clarify the prescription with the healthcare provider. This is crucial to ensure that the information is accurate and to provide safe and appropriate care. Option A is incorrect because blindly documenting without seeking clarification can lead to errors. Option C is incorrect as refusing to document the prescription altogether is not in the best interest of the patient. Option D is also incorrect as speaking with the client's family is not the appropriate step to clarify a verbal prescription; the healthcare provider should be the primary source for this clarification.

4. A client is experiencing chest pain. Which action should the nurse take first?

• A. Administer aspirin
• B. Provide oxygen
• C. Perform an ECG
• D. Administer nitroglycerin

Correct answer: D

Rationale: Administering nitroglycerin is the priority action when a client is experiencing chest pain as it helps alleviate the pain caused by reduced blood flow to the heart. Oxygen can be beneficial, but nitroglycerin takes precedence in this situation. Aspirin can also be given, but nitroglycerin is the priority. Performing an ECG can provide valuable information but is not the first action to take in this scenario.

5. A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?

• A. Oral mucosa
• B. Conjunctivae
• C. Soles of the feet
• D. Ear lobes

Correct answer: A

Rationale: Central cyanosis is best assessed by examining the oral mucosa, as it is a more reliable indicator compared to other areas like the conjunctivae, soles of the feet, and ear lobes. The oral mucosa reflects the oxygen saturation levels of the blood more accurately. Conjunctivae and ear lobes may show cyanosis, but they are not as reliable as the oral mucosa. The soles of the feet are not typically used to assess central cyanosis.

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