Nursing Elites

1. A caregiver is caring for a 5-month-old infant who has manifestations of severe dehydration and a prescription for parenteral fluid therapy. The caregiver asks, 'What are the indications that my baby needs an IV?' Which of the following responses should the caregiver make?

• A. Your baby needs an IV because she is not producing any tears
• B. Your baby needs an IV because her fontanels are bulging
• C. Your baby needs an IV because she is breathing slower than normal
• D. Your baby needs an IV because her heart rate is decreasing

Correct answer: A

Rationale: The correct response is A: 'Your baby needs an IV because she is not producing any tears.' In infants, the inability to produce tears is a sign of severe dehydration. This is a crucial indication for the need for intravenous (IV) fluid therapy to rehydrate the infant. While the other options may also be symptoms of dehydration, the absence of tears is a more direct and specific indicator requiring immediate attention and intervention.

2. Which of the following actions will most likely lead to a break in the sterile technique for respiratory isolation?

• A. Opening the patient’s window to the outside environment
• B. Turning on the patient’s room ventilator
• C. Opening the door of the patient’s room leading into the hospital corridor
• D. Failing to wear gloves when administering a bed bath

Correct answer: D

Rationale: Failure to wear gloves during a bed bath can potentially introduce pathogens, compromising the sterile technique necessary for respiratory isolation. Proper hand hygiene and personal protective equipment are crucial to prevent the transmission of infectious agents in such settings.

3. A patient requires augmentation of labor. Which of the following conditions should the nurse recognize as a contraindication to the use of oxytocin?

• A. Diabetes mellitus
• B. Shoulder presentation
• C. Postterm with oligohydramnios
• D. Chorioamnionitis

Correct answer: C

Rationale: Postterm pregnancy with oligohydramnios is a contraindication for the use of oxytocin due to the increased risk of uterine hyperstimulation and fetal distress. Oxytocin can further stress the fetus in this scenario, potentially leading to adverse outcomes. Therefore, it is crucial for the nurse to recognize this contraindication to ensure the safety of both the mother and the baby during labor.

4. The nurse observes that Mr. Adams begins to have increased difficulty breathing. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. The nurse documents this breathing as:

• A. Tachypnea
• B. Eupnea
• C. Orthopnea
• D. Hyperventilation

Correct answer: C

Rationale: Orthopnea is a condition where a person experiences difficulty breathing when lying flat but finds relief when sitting up or standing. Elevating the head of the bed to the high Fowler position helps alleviate this symptom. Tachypnea refers to rapid breathing, eupnea is normal breathing, and hyperventilation is breathing excessively fast or deep.

5. What is the initial technique used when examining a client's abdomen?

• A. Palpation
• B. Auscultation
• C. Percussion
• D. Inspection

Correct answer: D

Rationale: When examining a client's abdomen, the initial technique used is inspection. Inspection involves visually assessing the abdomen for any abnormalities, such as distention, scars, or rashes. This step allows the healthcare provider to gather valuable information before proceeding to other examination techniques like palpation, auscultation, and percussion. Palpation, auscultation, and percussion are secondary techniques used after visual inspection to further assess the abdomen for specific findings. Palpation involves feeling the abdomen for masses or tenderness, auscultation is listening for bowel sounds, and percussion is tapping the abdomen to assess for areas of dullness or resonance.

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