Nursing Elites

1. The nurse is caring for a client who is dying. While assessing the client for signs of impending death, the nurse observes the client for:

• A. elevated blood pressure.
• B. Cheyne-Stokes respiration.
• C. elevated pulse rate.
• D. decreased temperature.

Correct answer: B

Rationale: Cheyne-Stokes respirations are a pattern of breathing characterized by rhythmic waxing and waning of respirations from very deep to very shallow breathing with periods of temporary apnea. This pattern is often associated with conditions like cardiac failure and can be a sign of impending death. Elevated blood pressure and pulse rate are not typically associated with the dying process. Decreased temperature is also not a common sign of impending death. Therefore, option B, Cheyne-Stokes respiration, is the correct choice when assessing a client for signs of impending death.

2. A client can receive the mumps, measles, rubella (MMR) vaccine if he or she:

• A. is pregnant.
• B. is immunocompromised.
• C. is allergic to neomycin.
• D. has a cold.

Correct answer: D

Rationale: A client can receive the MMR vaccine if he or she has a cold. A simple cold without fever does not preclude vaccination. Pregnant women and immunocompromised individuals cannot receive the MMR vaccine due to the live rubella component, which may lead to birth defects or disease. Choice C is incorrect because individuals with anaphylactic reactions to neomycin should not receive the measles vaccine according to the American Academy of Pediatrics.

3. The new mother asks why her baby has lost weight since he was born. The best explanation of the weight loss is:

• A. The baby is dehydrated due to polyuria.
• B. The baby is hypoglycemic due to lack of glucose.
• C. The baby is allergic to the formula the mother is giving him.
• D. The baby can lose up to 10% of weight due to meconium stool, loss of extracellular fluid, and initiation of breastfeeding.

Correct answer: D

Rationale: After birth, newborns can lose weight due to meconium stool, loss of extracellular fluid, and the initiation of breastfeeding. This weight loss is a normal and expected physiological process, and infants can lose up to 10% of their birth weight during this period. There is no indication of dehydration (polyuria), hypoglycemia (lack of glucose), or allergy to the formula as reasons for weight loss in newborns. Therefore, answers A, B, and C are incorrect. Answer D provides the most accurate explanation for the observed weight loss in the newborn.

4. Which of the following statements by a client with spinal cord injury indicates a need for further teaching by the nurse regarding bowel management?

• A. "I should avoid eating foods that produce gas."?
• B. "I should drink more fluids like water and non-caffeinated fruit juices."?
• C. "I should set a regular schedule for bowel movements."?
• D. "I should sit in an upright position for bowel movements."?

Correct answer: B

Rationale: The corrected statement indicates the need for further teaching because it suggests consuming fluids like fruit juices, which can include caffeinated options that may stimulate fluid loss through increased urination. It is more appropriate to emphasize the consumption of fluids like water and non-caffeinated fruit juices for proper hydration. Choices A, C, and D demonstrate a correct understanding of bowel management by focusing on dietary considerations, establishing a regular bowel movement schedule, and using proper positioning during bowel movements. Option B is incorrect as it may lead to increased fluid loss due to caffeine content in some fruit juices.

5. A healthcare provider is preparing to assess the acoustic nerve during a neurological examination. To assess this nerve, the provider uses which technique?

• A. Uses a tuning fork
• B. Asks the client to puff out the cheeks
• C. Tests taste perception on the client's tongue
• D. Checks the client's ability to clench the teeth

Correct answer: A

Rationale: Testing of cranial nerve VIII (acoustic nerve) involves assessing hearing acuity through techniques like the whispered voice test and tuning fork tests (Weber and Rinne). Using a tuning fork helps determine if sound lateralizes to one ear (Weber) and compares air conduction to bone conduction (Rinne). Asking the client to puff out the cheeks is for cranial nerve VII (facial nerve) function evaluation. Testing taste perception on the tongue assesses cranial nerve IX (glossopharyngeal nerve) function. Checking the ability to clench teeth assesses cranial nerve V (trigeminal nerve) motor function.

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