Nursing Elites

1. A healthcare professional assesses a young adult in the emergency room following a motor vehicle accident. Which of the following neurological signs is of most concern?

• A. Flaccid paralysis
• B. Pupils fixed and dilated
• C. Diminished spinal reflexes
• D. Reduced sensory responses

Correct answer: B

Rationale: The correct answer is B: Pupils fixed and dilated. Fixed and dilated pupils are a critical neurological sign that indicates severe neurological damage or brain herniation, posing a significant concern for the patient's condition. Flaccid paralysis (choice A) typically indicates lower motor neuron injury, while diminished spinal reflexes (choice C) and reduced sensory responses (choice D) may suggest various neurological issues but are not as acutely concerning as fixed and dilated pupils in this scenario.

2. A client is recovering from a hip replacement and is taking Tylenol #3 every 3 hours for pain. In checking the client, which finding suggests a side effect of the analgesic?

• A. Bruising at the operative site
• B. Elevated heart rate
• C. Decreased platelet count
• D. No bowel movement for 3 days

Correct answer: D

Rationale: The correct answer is D. Constipation is a common side effect of Tylenol #3, which contains codeine. Codeine can slow down bowel movements, leading to constipation. Monitoring for constipation and implementing management strategies is crucial. Choices A, B, and C are incorrect because bruising at the operative site, elevated heart rate, and decreased platelet count are not commonly associated side effects of Tylenol #3.

3. A client wants to increase her daily intake of omega-3 fatty acids. Which of the following foods should the nurse suggest the client increase?

• A. Blueberries
• B. Soybean oil
• C. Citrus fruits
• D. Green tea

Correct answer: B

Rationale: The correct answer is B: Soybean oil. Soybean oil is a good source of omega-3 fatty acids, which are beneficial for heart health. Blueberries (choice A), citrus fruits (choice C), and green tea (choice D) are not significant sources of omega-3 fatty acids. Blueberries are rich in antioxidants, citrus fruits provide vitamin C, and green tea contains polyphenols, but they do not offer a substantial amount of omega-3 fatty acids compared to soybean oil.

4. A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) 4 hours ago. Labor is to be induced. At the time of the ROM the vital signs were T-99.8 degrees F, P-84, R-20, BP-130/78, and fetal heart tones (FHT) 148 beats/min. Which assessment findings taken now may be an early indication that the client is developing a complication of labor?

• A. FHT 168 beats/min
• B. Temperature 100 degrees Fahrenheit
• C. Cervical dilation of 4 cm
• D. BP 138/88

Correct answer: A

Rationale: The correct answer is A. Fetal heart rate elevation can indicate distress, making it an early sign of labor complications. Choices B, C, and D are not the best answers in this scenario. Choice B, an elevated temperature, could indicate infection but is not a direct sign of labor complications. Choice C, cervical dilation of 4 cm, is a normal part of labor progression for a primigravida. Choice D, a blood pressure of 138/88, falls within normal limits and is not an early indication of labor complications.

5. Which of these clients, all in the terminal stage of cancer, is least appropriate to suggest the use of patient-controlled analgesia (PCA) with a pump?

• A. A young adult with a history of Down syndrome
• B. A teenager who reads at a 4th-grade level
• C. An elderly client with numerous arthritic nodules on the hands
• D. A preschooler with intermittent alertness

Correct answer: D

Rationale: The correct answer is D, a preschooler with intermittent alertness. This client may not have the cognitive ability to effectively use a PCA pump due to their age and alertness level. They may not understand how to self-administer the analgesia. Choices A, B, and C are more appropriate candidates for PCA as they are likely to have better comprehension and ability to operate the PCA pump compared to a preschooler with intermittent alertness.

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