Nursing Elites

1. A nurse in a provider's office is assessing the motor skill development of a 15-month-old toddler during a well-child visit. What gross motor skills should the nurse expect to observe?

• A. Walks without assistance using a wide stance
• B. Climbs stairs with assistance
• C. Runs smoothly
• D. Kicks a ball forward

Correct answer: A

Rationale: The correct answer is A. At 15 months, toddlers typically walk independently but may do so with a wide stance for balance. Choice B, climbing stairs with assistance, is more common around 18 months. Choice C, running smoothly, is usually achieved around 2 years of age. Choice D, kicking a ball forward, generally develops around 2 to 3 years of age. Therefore, for a 15-month-old toddler, the nurse should expect the child to walk without assistance using a wide stance for balance.

2. A client with a new diagnosis of heart failure is prescribed furosemide. Which of the following instructions should the nurse include?

• A. Take the medication in the morning.
• B. Increase intake of potassium-rich foods.
• C. Report a decrease in urine output.
• D. Expect swelling in the lower extremities.

Correct answer: B

Rationale: The correct answer is to instruct the client to increase their intake of potassium-rich foods. Furosemide, a loop diuretic, can lead to potassium loss, which may cause hypokalemia. Increasing potassium intake can help prevent this electrolyte imbalance. Choice A is incorrect because furosemide is usually taken in the morning to prevent sleep disturbances due to increased urination. Choice C is incorrect because a decrease in urine output could indicate a problem and should be reported immediately. Choice D is incorrect because furosemide is used to reduce swelling in the body, including the lower extremities, so expecting swelling is not appropriate.

3. A nurse is assessing a client who reports a possible exposure to HIV. Which of the following findings should the nurse identify as an early manifestation of HIV infection?

• A. Stomatitis
• B. Fatigue
• C. Wasting syndrome
• D. Lipodystrophy

Correct answer: B

Rationale: The correct answer is B: Fatigue. A client with early HIV infection can be asymptomatic or experience symptoms like viral infections, such as fever, rash, and fatigue. Fatigue is a common early manifestation of HIV infection due to the body's immune response. Stomatitis (choice A) is more commonly associated with oral health issues or infections. Wasting syndrome (choice C) and lipodystrophy (choice D) are more advanced manifestations seen in later stages of HIV infection, characterized by severe weight loss and changes in body fat distribution, respectively.

4. A nurse is providing teaching to a client who has a new prescription for lisinopril. Which of the following statements by the client indicates a need for further teaching?

• A. I will notify my doctor if I develop a cough.
• B. I will avoid using salt substitutes.
• C. I will increase my intake of potassium-rich foods.
• D. I will monitor my blood pressure regularly.

Correct answer: C

Rationale: The correct answer is C. Clients taking lisinopril should avoid potassium-rich foods because ACE inhibitors can increase potassium levels, potentially leading to hyperkalemia. Choices A, B, and D are all correct statements. Clients should notify their doctor if they develop a cough as it can indicate a potential side effect of lisinopril. Avoiding salt substitutes is important as they may contain potassium chloride, which can also raise potassium levels. Monitoring blood pressure regularly is essential when taking an antihypertensive medication like lisinopril.

5. A nurse is preparing to perform a sterile dressing change for a client with a surgical wound. Which action should the nurse take to prevent contamination during the dressing change?

• A. Proceed with the dressing change
• B. Restart the procedure if the sterile solution splashes onto the sterile field
• C. Continue without concern for minor splashes
• D. Delegate the task to another nurse

Correct answer: B

Rationale: The correct action for the nurse to take to prevent contamination during a sterile dressing change is to restart the procedure if the sterile solution splashes onto the sterile field. Any contamination of the sterile field compromises the aseptic technique and increases the risk of infection for the client. Therefore, it is crucial to maintain the sterility of the field throughout the procedure. Choices A, C, and D are incorrect because proceeding with the dressing change, continuing without concern for minor splashes, or delegating the task to another nurse would all compromise the sterility of the procedure and increase the risk of infection for the client.

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