Nursing Elites

1. A nurse is caring for a client who has been taking haloperidol for several years. Which of the following assessment findings should the nurse recognize as a long-term side effect of this medication?

• A. Lip-smacking
• B. Agranulocytosis
• C. Clang association
• D. Alopecia

Correct answer: A

Rationale: Lip-smacking is a symptom of tardive dyskinesia, a long-term side effect of antipsychotic medications like haloperidol, characterized by involuntary movements of the face and jaw. Agranulocytosis (Choice B) is a rare but serious side effect of some medications, characterized by a dangerously low white blood cell count. Clang association (Choice C) is a thought disorder characterized by the association of words based on sound rather than meaning. Alopecia (Choice D) refers to hair loss, which is not a known long-term side effect of haloperidol.

2. A nurse is performing a vaginal exam on a client who is in active labor. The nurse notes the umbilical cord protruding through the cervix. Which of the following actions should the nurse take?

• A. Administer oxytocin to the client via intravenous infusion
• B. Apply oxygen at 2 L/min via nasal cannula
• C. Prepare for insertion of an intrauterine pressure catheter
• D. Assist the client into the knee-chest position

Correct answer: D

Rationale: The nurse should assist the client into the knee-chest position to relieve pressure on the umbilical cord. This position helps to prevent cord compression and improves fetal oxygenation. Administering oxytocin (Choice A) could worsen the situation by increasing contractions and potentially compressing the umbilical cord. Applying oxygen (Choice B) is not the priority in this emergency situation. Preparing for insertion of an intrauterine pressure catheter (Choice C) is not appropriate as the immediate concern is relieving pressure on the umbilical cord.

3. A nurse is caring for a client with a new prescription for lisinopril. Which of the following should the nurse monitor?

• A. Blood pressure
• B. Liver function
• C. Serum potassium levels
• D. Heart rate

Correct answer: A

Rationale: Corrected Rationale: Lisinopril is an ACE inhibitor commonly used to lower blood pressure. Monitoring blood pressure is crucial when initiating this medication to assess its effectiveness and potential side effects related to blood pressure regulation. Liver function monitoring is not typically required with lisinopril. While lisinopril can affect potassium levels, it is not the primary parameter to monitor when starting this medication. Heart rate monitoring is not a routine requirement when initiating lisinopril therapy.

4. A client is in the transition phase of labor. Which of the following actions should the nurse take?

• A. Assist the client to void every 3 hours
• B. Monitor contractions every 30 minutes
• C. Place the client in a lithotomy position
• D. Encourage the client to use a pant-blow breathing pattern

Correct answer: D

Rationale: Encouraging the client to use a pant-blow breathing pattern is crucial during the transition phase of labor. This phase is characterized by intense contractions and emotional responses. Pant-blow breathing helps manage pain and anxiety, providing comfort and support to the client. Voiding every 3 hours is not specific to the transition phase and may not address immediate needs. Monitoring contractions every 30 minutes is important but may not be as directly beneficial as focusing on coping mechanisms like breathing techniques. Placing the client in a lithotomy position is generally not recommended during the transition phase as it can impede progress and comfort.

5. A charge nurse is teaching a new nurse how to clean surfaces contaminated with blood. Which agent should the charge nurse include in the teaching?

• A. Hydrogen peroxide
• B. Chlorhexidine
• C. Isopropyl alcohol
• D. Chlorine bleach

Correct answer: D

Rationale: Chlorine bleach is the most appropriate agent for disinfecting surfaces contaminated with blood. It is effective in killing a wide range of pathogens, including viruses. Hydrogen peroxide (Choice A) is not as effective as chlorine bleach for bloodborne pathogen disinfection. Chlorhexidine (Choice B) and isopropyl alcohol (Choice C) are more commonly used for skin antisepsis rather than surface disinfection, making them less suitable options in this scenario.

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