Nursing Elites

1. A healthcare professional is completing a nutritional assessment on a client and measures body mass index (BMI). Which of the following readings correlates with a BMI of an overweight client?

• A. 18.5
• B. 24.9
• C. 25
• D. 32

Correct answer: C

Rationale: A BMI of 25-29.9 is considered overweight. Therefore, a BMI of 25 correlates with an overweight client. A BMI of 18.5-24.9 indicates a healthy weight. Choices A, B, and D are incorrect as they fall into the healthy weight or obese categories, not overweight.

2. A healthcare professional is preparing to administer a flu vaccine. Which of the following should the healthcare professional verify?

• A. Client's age
• B. Client's allergy to eggs
• C. Client's vaccination history
• D. Client's weight

Correct answer: C

Rationale: The healthcare professional should verify the client's vaccination history to ensure they are due for the flu vaccine. Verifying the client's age (choice A) is important for other vaccines but not specifically for the flu vaccine. While allergy to eggs (choice B) is relevant as the flu vaccine is traditionally produced in eggs, it is not the top priority for verification. The client's weight (choice D) is not directly related to the administration of the flu vaccine.

3. A nurse is caring for a client with a history of heroin use who is intoxicated. Which finding should the nurse expect?

• A. Constricted pupils
• B. Dilated pupils
• C. Increased reflexes
• D. Elevated blood pressure

Correct answer: A

Rationale: The correct answer is A: Constricted pupils. Constricted pupils are a classic sign of opioid intoxication, including heroin. Opioids like heroin cause the pupils to constrict due to their effect on the autonomic nervous system. Dilated pupils, increased reflexes, and elevated blood pressure are not typically associated with opioid intoxication but may be seen with other substances or conditions.

4. A nurse is caring for a client who has been receiving oxytocin IV for labor augmentation. The client's contractions are occurring every 2 minutes and lasting 90 seconds. What action should the nurse take?

• A. Decrease the oxytocin infusion
• B. Discontinue the oxytocin infusion
• C. Increase the IV fluid rate
• D. Apply an internal fetal monitor

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to discontinue the oxytocin infusion. The client is experiencing uterine hyperstimulation, as evidenced by contractions occurring every 2 minutes and lasting 90 seconds. Discontinuing the oxytocin is crucial to prevent fetal distress and uterine rupture. Increasing the IV fluid rate would not address the uterine hyperstimulation caused by oxytocin. Applying an internal fetal monitor is not the priority at this moment; first, the oxytocin infusion needs to be stopped to manage the uterine hyperstimulation effectively.

5. A nurse is caring for a client who is in active labor. The nurse notes early decelerations in the FHR on the fetal monitor tracing. The nurse should identify that which of the following conditions causes early decelerations in the FHR?

• A. Fetal hypoxemia
• B. Cord compression
• C. Uteroplacental insufficiency
• D. Head compression

Correct answer: D

Rationale: Early decelerations are caused by head compression during contractions, which is a normal response as the fetal head is being compressed during uterine contractions. This usually indicates that the fetus is descending into the birth canal. Choices A, B, and C are incorrect. Fetal hypoxemia, cord compression, and uteroplacental insufficiency typically present with variable or late decelerations on the fetal heart rate tracing, not early decelerations.

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