Nursing Elites

1. A nurse is preparing to administer a measles, mumps, and rubella (MMR) vaccine to an adult client. Which of the following is a contraindication to this vaccine?

• A. The possibility of pregnancy within 4 weeks
• B. Client allergy to strawberry
• C. Client history of genital herpes
• D. The possibility of overseas travel in the next month

Correct answer: A

Rationale: The correct answer is A. The MMR vaccine is contraindicated in pregnant women due to the risk of fetal harm. It is recommended that women avoid becoming pregnant for at least 4 weeks after receiving the vaccine. Choice B, client allergy to strawberry, is not a contraindication for the MMR vaccine. Choice C, client history of genital herpes, is not a contraindication for the MMR vaccine. Choice D, the possibility of overseas travel in the next month, is not a contraindication for the MMR vaccine.

2. A nurse is in the emergency department monitoring the hydration status of a client receiving oral rehydration. What should the nurse intervene for?

• A. Heart rate 120/min
• B. Urine output 30 mL/hour
• C. Blood pressure 110/70 mmHg
• D. Skin turgor is normal

Correct answer: A

Rationale: A heart rate of 120/min may indicate dehydration or inadequate hydration, prompting the need for IV fluid replacement. Elevated heart rate is a sensitive indicator of dehydration as the body attempts to maintain cardiac output. Urine output of 30 mL/hour is within the normal range (30 mL/hour is the minimum acceptable urine output for an adult). Blood pressure of 110/70 mmHg is within the normal range. Normal skin turgor is a positive sign indicating adequate hydration.

3. A client with Ménière’s disease is experiencing episodes of vertigo. Which of the following interventions should the nurse include in the plan?

• A. Encourage bed rest
• B. Restrict fluid intake to the morning hours
• C. Administer aspirin
• D. Provide a low sodium diet

Correct answer: D

Rationale: The correct intervention for a client with Ménière’s disease experiencing vertigo is to provide a low sodium diet. Limiting sodium helps to reduce fluid retention, which in turn decreases the manifestations of Ménière’s disease. Encouraging bed rest (Choice A) may be necessary during acute episodes but is not a long-term solution. Restricting fluid intake (Choice B) to the morning hours does not specifically address the underlying issue of fluid retention associated with Ménière’s disease. Administering aspirin (Choice C) is not recommended for Ménière’s disease as it can worsen symptoms.

4. A client with HIV and neutropenia requires specific care from the nurse. Which of the following precautions should the nurse take while caring for this client?

• A. Wear an N95 respirator while caring for the client.
• B. Use a dedicated stethoscope for the client.
• C. Insert an indwelling urinary catheter to monitor urinary output.
• D. Monitor the client’s vital signs every 8 hours.

Correct answer: B

Rationale: Using dedicated equipment for a neutropenic client, such as a stethoscope, helps prevent infections. Neutropenic clients have a weakened immune system, making them vulnerable to infections from common pathogens. Wearing an N95 respirator is not necessary unless airborne precautions are required. Inserting a urinary catheter should be avoided unless necessary to prevent introducing pathogens. Monitoring vital signs should be done more frequently, typically every 4 hours, to promptly identify any changes in the client's condition.

5. A nurse is caring for a client prescribed levetiracetam. Which of the following should the nurse monitor?

• A. Liver function
• B. Blood glucose levels
• C. Serum creatinine
• D. Blood pressure

Correct answer: C

Rationale: The correct answer is C: Serum creatinine. Levetiracetam requires monitoring of renal function, specifically serum creatinine levels, as it is primarily eliminated by the kidneys. Monitoring liver function (Choice A) is not necessary for levetiracetam. Blood glucose levels (Choice B) are typically not affected by levetiracetam. While monitoring blood pressure (Choice D) is important in general patient care, it is not specifically required for clients prescribed levetiracetam.

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