Nursing Elites

1. A healthcare professional is preparing to administer a hepatitis B vaccine. Which of the following should the healthcare professional verify?

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

Correct answer: B

Rationale: The correct answer is B: Client's vaccination history. Before administering the hepatitis B vaccine, it is essential to verify the client's vaccination history to ensure they are due for the vaccine. This helps in preventing unnecessary vaccinations and ensures the appropriate timing and dosage. Option A, the client's allergy to eggs, is not directly related to administering the hepatitis B vaccine. Option C, the client's weight, and option D, the client's blood pressure, are not factors that need to be specifically verified before administering the hepatitis B vaccine.

2. A community health nurse is teaching a group of clients about first aid for wounds. Which client statement indicates understanding?

• A. Remove blood-saturated dressings
• B. Apply clean dressings over the saturated ones and hold pressure
• C. Elevate the wound above heart level
• D. Leave the wound open to air

Correct answer: B

Rationale: The correct answer is B. Applying clean dressings over blood-saturated ones and holding pressure helps to control bleeding and prevent tissue disruption. Removing blood-saturated dressings can cause further damage by disrupting the forming clot. Elevating the wound above heart level is beneficial to reduce swelling, but it is not the best immediate action for a blood-saturated dressing. Leaving the wound open to air can increase the risk of infection and slow down the healing process.

3. A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations of the FHR. Which of the following actions should the nurse take first?

• A. Prepare the equipment necessary to initiate an amnioinfusion
• B. Administer oxygen at 10 L/min via a non-rebreather face mask
• C. Discontinue the infusion of oxytocin
• D. Place the client in a left lateral position

Correct answer: C

Rationale: The correct first action for the nurse to take is to discontinue the infusion of oxytocin. Oxytocin can lead to uterine hyperstimulation and fetal distress, contributing to variable decelerations in fetal heart rate. By stopping the oxytocin infusion, the nurse can promptly assess and manage the fetal heart rate. Choice A, preparing for amnioinfusion, is not the priority when faced with recurrent variable decelerations. Choice B, administering oxygen, is important but addressing the oxytocin infusion issue takes precedence. Choice D, placing the client in a left lateral position, is beneficial for optimizing fetal oxygenation but discontinuing oxytocin is the initial step in managing variable decelerations.

4. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate. The nurse should monitor the client for which of the following findings as an indication of magnesium toxicity?

• A. Decreased deep tendon reflexes
• B. Elevated blood pressure
• C. Increased urinary output
• D. Hyperreflexia

Correct answer: A

Rationale: The correct answer is A: Decreased deep tendon reflexes. Magnesium sulfate toxicity can lead to diminished deep tendon reflexes, respiratory depression, and decreased urine output. Diminished deep tendon reflexes are an early sign of magnesium toxicity and indicate the need to discontinue the infusion. Elevated blood pressure (choice B) is not typically associated with magnesium toxicity. Increased urinary output (choice C) is also not a common finding in magnesium toxicity. Hyperreflexia (choice D) is not consistent with the expected findings of magnesium toxicity, which typically causes decreased reflexes.

5. A nurse is planning care for a client who has chronic renal failure. Which action should the nurse include in the plan of care?

• A. Encourage increased fluid intake
• B. Restrict protein intake to the RDA
• C. Increase dietary potassium
• D. Encourage foods high in sodium

Correct answer: B

Rationale: The correct action the nurse should include in the plan of care for a client with chronic renal failure is to restrict protein intake to the RDA. This is important because limiting protein helps reduce the buildup of waste products that the kidneys are unable to efficiently excrete. Encouraging increased fluid intake (choice A) may further burden the kidneys, increasing the risk of fluid overload. Increasing dietary potassium (choice C) is not recommended in chronic renal failure as impaired kidneys have difficulty regulating potassium levels. Encouraging foods high in sodium (choice D) is also not appropriate as excessive sodium intake can lead to fluid retention and hypertension, which are detrimental in renal failure.

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