Nursing Elites

1. A healthcare provider is assessing a client who has severe dehydration. Which finding indicates effective treatment?

• A. Sunken anterior fontanel
• B. Tenting skin turgor
• C. Flat anterior fontanel
• D. Hyperpnea

Correct answer: C

Rationale: A flat anterior fontanel indicates effective treatment for dehydration in infants. Dehydration often causes sunken fontanels, so when the anterior fontanel becomes flat, it suggests that rehydration has occurred. Sunken anterior fontanel (Choice A) is a sign of dehydration, not effective treatment. Tenting skin turgor (Choice B) is also a sign of dehydration, indicating poor skin turgor. Hyperpnea (Choice D) is increased depth and rate of breathing and is not directly related to the hydration status of the client.

2. A nurse is caring for a client in preterm labor who is receiving magnesium sulfate. Which of the following is an indication of magnesium toxicity?

• A. Blood glucose of 160 mg/dL
• B. Urine output of 20 mL/hour
• C. Systolic BP of 140 mm Hg
• D. Respiratory rate of 20/min

Correct answer: B

Rationale: The correct answer is B: Urine output of 20 mL/hour. Urine output below 30 mL/hour is a sign of magnesium toxicity due to the risk of accumulation in the body. Choices A, C, and D are not indicative of magnesium toxicity. Elevated blood glucose, systolic blood pressure, and normal respiratory rate are not specific signs of magnesium toxicity.

3. A nurse is caring for a client prescribed ferrous sulfate for the treatment of anemia. Which of the following instructions should be included in client teaching about this medication?

• A. Take the medication on an empty stomach
• B. Notify your provider if your stool becomes dark green
• C. Decrease dietary fiber intake while taking this medication
• D. Take prescribed antacids at the same time as this medication

Correct answer: A

Rationale: The correct instruction for a client prescribed ferrous sulfate for anemia is to take the medication on an empty stomach. This is because ferrous sulfate is best absorbed in an acidic environment, which is enhanced on an empty stomach. However, if the client experiences gastrointestinal side effects, they can take the medication with food. Choice B, notifying the provider if stool becomes dark green, is correct because dark or black stools are common with iron therapy and not a cause for concern. Choice C, decreasing dietary fiber intake, is incorrect as dietary fiber does not interfere with the absorption of ferrous sulfate. Choice D, taking prescribed antacids at the same time, is incorrect as antacids can decrease the absorption of ferrous sulfate.

4. A healthcare provider is preparing to administer a dose of clindamycin. Which of the following should the provider assess first?

• A. Allergy history
• B. Vital signs
• C. Renal function
• D. Liver function

Correct answer: A

Rationale: When preparing to administer clindamycin, assessing the patient's allergy history is crucial as clindamycin can cause severe allergic reactions. This assessment helps identify any potential risks related to allergies and enables the healthcare provider to take necessary precautions. Vital signs, renal function, and liver function are also important assessments before administering medications, but in this case, checking for any history of allergies takes priority due to the risk of severe allergic reactions associated with clindamycin.

5. A nurse is caring for a newborn diagnosed with necrotizing enterocolitis (NEC). Which of the following interventions should the nurse expect to implement?

• A. Withhold oral feedings
• B. Measure abdominal girth
• C. Position the newborn supine
• D. Apply cold compresses to the abdomen

Correct answer: B

Rationale: Measuring abdominal girth is crucial in monitoring for signs of abdominal distension, which is a key indicator of worsening necrotizing enterocolitis (NEC). It helps in assessing the progression of the condition. Positioning the newborn supine, as in choice C, can help relieve pressure on the abdomen but does not directly monitor the condition. Applying cold compresses, as in choice D, is not recommended for NEC as it can constrict blood vessels and potentially worsen the condition. Withholding oral feedings, as in choice A, is also important to rest the bowel and prevent further complications, but measuring abdominal girth is more directly related to monitoring the progression of NEC.

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