Nursing Elites

1. A nurse is caring for a 7-month-old infant being treated for severe dehydration. Which finding indicates treatment has been effective?

• A. Skin turgor displays tenting
• B. Flat anterior fontanel
• C. Cool, mottled skin
• D. Hyperpnea

Correct answer: B

Rationale: A flat anterior fontanel indicates improved hydration in infants, as dehydration typically causes sunken fontanels.

2. A nurse is caring for a client who is receiving oxytocin to augment labor. The client has an intrauterine pressure catheter and an internal fetal scalp electrode for monitoring. Which of the following is an indication that the nurse should discontinue the infusion?

• A. Contraction frequency every 3 minutes
• B. Contraction duration of 100 seconds
• C. Fetal heart rate with moderate variability
• D. Fetal heart rate of 118/min

Correct answer: B

Rationale: A contraction duration of 100 seconds indicates potential uterine hyperstimulation, which can lead to fetal distress and decreased uterine perfusion. Prolonged contractions may reduce oxygen supply to the fetus, putting it at risk. Discontinuing the oxytocin infusion is crucial to prevent adverse effects on both the mother and the fetus. The other options do not raise immediate concerns that would necessitate discontinuing the oxytocin infusion. Contraction frequency every 3 minutes is within a normal range. Fetal heart rate with moderate variability and a rate of 118/min are both reassuring signs of fetal well-being.

3. When teaching a client about the correct use of a cane, what should the nurse include?

• A. Ensure the cane has a rubber cap
• B. Hold the cane on the stronger side
• C. Flex the elbow slightly when using the cane
• D. Use a quad cane for increased support

Correct answer: B

Rationale: When using a cane, it should be held on the stronger side to provide optimal support and stability. This positioning allows the cane to bear weight effectively and helps in improving balance. Option A about ensuring the cane has a rubber cap is important for preventing slipping but is not directly related to the correct use of the cane. Option C, flexing the elbow slightly, is a general guideline and may vary depending on the individual's height and the type of cane being used. Option D suggesting the use of a quad cane for increased support is not necessary if a standard cane is sufficient for the client's needs.

4. A nurse is caring for a client prescribed the HMG CoA reductase inhibitor, atorvastatin. Which of the following should be monitored while this medication is prescribed?

• A. Liver function test
• B. Renal function test
• C. Hearing screenings
• D. Visual acuity screenings

Correct answer: A

Rationale: Corrected Rationale: Atorvastatin, an HMG CoA reductase inhibitor, can lead to hepatotoxicity. Therefore, monitoring liver function through regular tests is essential. Baseline liver function should be assessed, followed by tests at 12 weeks after starting therapy and periodically thereafter. This monitoring helps detect early signs of liver damage, including jaundice, nausea, and dark urine. Incorrect Choices Rationale: B) Renal function test is not directly affected by atorvastatin. C) Hearing screenings and D) Visual acuity screenings are not indicated for monitoring while on atorvastatin therapy.

5. A nurse is preparing to administer regular insulin and NPH insulin. What is the proper sequence of events the nurse should follow?

• A. Inspect the vials for contamination.
• B. Withdraw regular insulin first, then NPH.
• C. Inject air into the NPH insulin vial first.
• D. Roll the NPH insulin vial between the hands to mix.

Correct answer: A

Rationale: The correct sequence of events for administering regular insulin and NPH insulin begins with inspecting the vials for contamination to ensure patient safety. Rolling the NPH insulin vial between the hands to mix and injecting air into the NPH insulin vial should follow the inspection step. Afterward, the nurse should inject air into the regular insulin vial and then withdraw the regular insulin first. Option A is the correct answer as it outlines the initial crucial step in the administration process. Option B is incorrect as it provides the incorrect order of withdrawing the insulins. Option C is incorrect as injecting air into the NPH insulin vial should come after inspecting the vials. Option D is incorrect as rolling the NPH insulin vial should be done after inspecting the vials and injecting air into the NPH insulin vial.

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