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 preparing to administer a dose of enoxaparin. Which of the following actions should the nurse take?

• A. Administer it intramuscularly
• B. Monitor APTT levels
• C. Give it in the abdomen
• D. Administer rapidly

Correct answer: C

Rationale: The correct answer is to give enoxaparin in the abdomen. Enoxaparin is usually administered subcutaneously in the abdomen to avoid muscle irritation. Choice A is incorrect because enoxaparin should not be administered intramuscularly. Choice B is incorrect as monitoring APTT levels is not directly related to administering enoxaparin. Choice D is incorrect as enoxaparin should be administered slowly to prevent bruising or bleeding at the injection site.

3. A nurse is preparing to feed a newly admitted client with dysphagia. Which of the following actions should the nurse take?

• A. Instruct the client to lift their chin when swallowing
• B. Discourage the client from coughing during feedings
• C. Sit at or below the client’s eye level during feedings
• D. Talk with the client during feedings

Correct answer: C

Rationale: The correct answer is C. Sitting at or below the client’s eye level is important when feeding a client with dysphagia. This position allows the nurse to closely observe the client for any signs of difficulty with swallowing, which can help prevent aspiration. Instructing the client to lift their chin when swallowing (choice A) is not recommended for clients with dysphagia as it can increase the risk of aspiration. Discouraging the client from coughing during feedings (choice B) is also not correct, as coughing may be a protective mechanism to prevent aspiration. Talking with the client during feedings (choice D) may distract the client and interfere with their ability to focus on swallowing safely.

4. A nurse is planning care for four clients. Which client is the highest priority?

• A. Client with dry, black eschar on the heel
• B. Client wearing an arm cast and reporting numb fingers
• C. Client with reddened skin around the coccyx
• D. Client with frequent incontinence

Correct answer: B

Rationale: The correct answer is B because numb fingers indicate neurovascular compromise, which can lead to serious complications if not addressed promptly. The priority in this situation is to assess and address any circulation issues affecting the extremity. Choices A, C, and D are of concern but not as immediate as neurovascular compromise, which requires urgent attention to prevent further complications.

5. A nurse is teaching a client about the use of gabapentin. Which of the following should be included?

• A. It can cause drowsiness
• B. It has no side effects
• C. It is a pain reliever
• D. It can be taken with food

Correct answer: A

Rationale: The correct answer is A: 'It can cause drowsiness.' Gabapentin is known to cause drowsiness, and clients should be warned about this side effect. Choice B is incorrect because gabapentin, like any medication, can have side effects. Choice C is incorrect because although gabapentin is used for pain management, it is not classified as a pain reliever. Choice D is incorrect because gabapentin should be taken as prescribed by the healthcare provider, and specific instructions regarding food intake should be provided based on individual needs.

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