Nursing Elites

1. A nurse is assessing a client who is receiving chemotherapy and has stomatitis. Which of the following findings should the nurse expect?

• A. Dry, cracked lips
• B. Bleeding gums
• C. Foul-smelling breath
• D. Red, open sores in the mouth

Correct answer: D

Rationale: The correct answer is D: Red, open sores in the mouth. Stomatitis, a common side effect of chemotherapy, presents with red, open sores in the mouth, which can be painful and increase the risk of infection. Choices A, B, and C are incorrect because stomatitis typically does not manifest as dry, cracked lips, bleeding gums, or foul-smelling breath.

2. A nurse is caring for a client who is in labor and has a diagnosis of group B streptococcus ß-hemolytic infection. Which of the following medications should the nurse plan to administer?

• A. Ampicillin
• B. Azithromycin
• C. Ceftriaxone
• D. Acyclovir

Correct answer: A

Rationale: Ampicillin is the correct choice for treating group B streptococcus infections in pregnant women during labor to prevent neonatal infection. Group B streptococcus is commonly treated with penicillin or ampicillin; therefore, choices B, C, and D are incorrect. Azithromycin is not the first-line treatment for group B streptococcus. Ceftriaxone is not the preferred antibiotic for this infection during labor. Acyclovir is an antiviral medication used for herpes simplex virus infections, not bacterial infections like group B streptococcus.

3. A client with multiple sclerosis reports diplopia. Which of the following actions should the nurse take?

• A. Encourage the client to focus on a distant object.
• B. Apply a warm compress to the client’s eyes.
• C. Recommend alternating eye patches during the day.
• D. Administer artificial tears.

Correct answer: C

Rationale: The correct action for the nurse to take when caring for a client with multiple sclerosis reporting diplopia is to recommend alternating eye patches during the day. This strategy can help relieve diplopia (double vision) by allowing each eye to rest alternately, reducing eye strain. Encouraging the client to focus on a distant object (Choice A) is not an appropriate intervention for diplopia in this case. Applying a warm compress to the client's eyes (Choice B) and administering artificial tears (Choice D) are not effective interventions for diplopia associated with multiple sclerosis.

4. A client who is 2 hours postpartum reports heavy bleeding and passing large clots. What is the nurse's priority action?

• A. Perform fundal massage
• B. Administer oxytocin IV
• C. Check vital signs
• D. Encourage the client to void

Correct answer: A

Rationale: The correct answer is A: Perform fundal massage. Fundal massage promotes uterine contractions, which is the initial action to reduce postpartum hemorrhage caused by uterine atony. Checking vital signs (choice C) is important but not the priority when active bleeding is present. Administering oxytocin IV (choice B) may be needed but is not the priority action. Encouraging the client to void (choice D) does not address the underlying issue of postpartum hemorrhage and should not be the priority.

5. A nurse is caring for a client who has increased intracranial pressure (ICP). Which of the following interventions should the nurse implement?

• A. Place several pillows behind the client’s head
• B. Place the client in a Sims' position
• C. Keep the client’s neck in a midline position
• D. Maintain flexion of the client’s hips at a 90° angle

Correct answer: C

Rationale: Keeping the client’s neck in a midline position is essential when caring for a client with increased intracranial pressure (ICP) as it helps promote optimal blood flow and reduces the risk of further increasing ICP. Placing pillows behind the client’s head (Choice A) may not be recommended as it could potentially increase ICP. Putting the client in a Sims' position (Choice B) and maintaining hip flexion at a 90° angle (Choice D) are not directly related to managing increased ICP and are not the priority interventions in this situation.

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