Nursing Elites

1. A nurse in the healthcare provider's office is checking the Babinski reflex in a 3-month-old infant. The nurse determines that the infant's response is normal if which finding is noted?

• A. The fingers curl tightly, and the toes curl forward.
• B. The toes flare, and the big toe is dorsiflexed.
• C. There is extension of the extremities on the side to which the head is turned, with flexion on the opposite side.
• D. The infant turns to the side that is touched.

Correct answer: B

Rationale: To elicit the Babinski reflex, the nurse strokes the lateral sole of the foot from the heel to across the base of the toes. In the expected response, the toes flare, and the big toe dorsiflexes. The Babinski reflex disappears at 12 months of age. Turning to the side that is touched is the expected response when the rooting reflex is elicited. Tight curling of the fingers and forward curling of the toes is the expected response when the grasp reflex (palmar and plantar) is elicited. Extension of the extremities on the side to which the head is turned with flexion on the opposite side is the expected response when the tonic neck reflex is elicited.

2. The LPN is about to give 100 mg Lopressor (metoprolol) to a client. Before administering the drug, they take the patient's vitals, which are as follows: Pulse: 58 Blood Pressure: 90/62 Respirations: 18/minute What action should the LPN take?

• A. Give the client half the prescribed dose and report the findings to the RN on duty.
• B. Give the client double the dose and report the findings to the RN on duty.
• C. Administer the drug and report the findings to the RN on duty.
• D. Hold the drug and report the findings to the RN on duty.

Correct answer: D

Rationale: Lopressor is given to treat hypertension, and a pulse of 58 and a blood pressure of 90/62 are considered low. To prevent the client from bottoming out, the drug should be held, and the findings reported to the RN, who should consult with the attending physician. LPNs should never adjust client dosing, as that is outside of their scope of practice. It is crucial to follow facility guidelines, which often recommend holding blood pressure medication at 60 bpm and a systolic pressure of 90 or less. By holding the drug and notifying the RN, the LPN ensures the client's safety and allows for appropriate assessment and decision-making by the healthcare team. Giving half the dose or double the dose without proper authorization can lead to serious complications and is considered unsafe practice.

3. What is the threshold of dextrose concentrations that can safely be administered through a peripheral IV?

• A. Dextrose concentrations below 20% can be safely administered through a peripheral IV; dextrose concentrations above 20% should not be administered through a peripheral IV.
• B. Dextrose concentrations below 5% can be safely administered through a peripheral IV; dextrose concentrations above 5% should not be administered through a peripheral IV.
• C. Dextrose concentrations below 10% can be safely administered through a peripheral IV; dextrose concentrations above 10% should not be administered through a peripheral IV.
• D. Dextrose concentrations above 5% can be safely administered through a peripheral IV; dextrose concentrations below 5% should not be administered through a peripheral IV.

Correct answer: C

Rationale: Dextrose concentrations below 10% are considered safe for administration through a peripheral IV, as concentrations above this threshold can lead to phlebitis, causing inflammation of the vein. Concentrations above 10% should not be administered through a peripheral IV to prevent vein irritation. Choice A is incorrect because concentrations above 20% are too high for a peripheral IV. Choice B is incorrect as dextrose concentrations below 5% are too low to be effective. Choice D is incorrect because the statement is reversed, suggesting that concentrations above 5% are safe, which is not true.

4. Which of the following physical findings indicates that an 11-12-month-old child is at risk for developmental dysplasia of the hip?

• A. refusal to walk
• B. not pulling to a standing position
• C. negative Trendelenburg sign
• D. negative Ortolani sign

Correct answer: B

Rationale: The correct answer is 'not pulling to a standing position.' An 11-12-month-old child not pulling to a standing position may be at risk for developmental dysplasia of the hip. By this age, children typically pull to a standing position, and failure to do so should raise concerns. Refusal to walk is a broader observation and not specific to hip dysplasia. The Trendelenburg sign indicates weakness of the gluteus medius muscle, not hip dysplasia. The Ortolani sign is used to detect congenital subluxation or dislocation of the hip, which is different from developmental dysplasia of the hip.

5. When teaching a woman about possible side effects of hormone replacement therapy, the nurse should include information about all of the following except:

• A. Hypoglycemia in diabetic women.
• B. The possible return of monthly menses when taking combination hormones.
• C. Increased risk of gallbladder disease.
• D. Increased risk of breast, cervical, and ovarian cancer with long-term use.

Correct answer: A

Rationale: The correct answer is 'Hypoglycemia in diabetic women.' When educating a woman about hormone replacement therapy, it is important to discuss the possible side effects. It is true that monthly menses might return when taking combination hormones, as the progestin can cause this. Additionally, there is an increased risk of gallbladder disease associated with hormone replacement therapy. Furthermore, long-term use of hormone replacement therapy is linked to an increased risk of breast, cervical, and ovarian cancer. However, hypoglycemia is not a common side effect of hormone replacement therapy, especially in diabetic women. In fact, estrogen can have a positive impact on glucose control in some cases, so hypoglycemia would not be a typical concern.

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