Nursing Elites

1. A nurse is preparing to administer a measles, mumps, rubella (MMR) immunization to a child. Which is a contraindication for this vaccine?

• A. Recent blood transfusion
• B. Allergy to penicillin
• C. Minor acute illness
• D. Low-grade fever

Correct answer: A

Rationale: The correct answer is A: Recent blood transfusion. A recent blood transfusion can interfere with the effectiveness of the MMR vaccine, making it a contraindication. Choice B, allergy to penicillin, is not a contraindication for the MMR vaccine. Choice C, minor acute illness, is not a contraindication unless the child has a moderate to severe illness. Choice D, low-grade fever, is not a contraindication as long as the child does not have a moderate to severe febrile illness.

2. A client with burn injuries covering their upper body is concerned about their altered appearance. Which of the following statements should the nurse make?

• A. “It is okay to not want to touch the burned areas of your body.”
• B. “Cosmetic surgery should be performed within the next year to be effective.”
• C. “Reconstructive surgery can completely restore your previous appearance.”
• D. “It could be helpful for you to attend a support group for people who have burn injuries.”

Correct answer: D

Rationale: The nurse should encourage the client to attend a support group for individuals with burn injuries. Support groups can provide emotional support, promote acceptance of altered appearance, and help the client cope with the changes. Choice A is incorrect because it may not address the client's emotional needs. Choice B is incorrect as suggesting a timeline for cosmetic surgery may not be appropriate without considering the client's physical and emotional readiness. Choice C is incorrect as reconstructive surgery may not completely restore the client's previous appearance and may set unrealistic expectations.

3. A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect?

• A. Butterfly rash on the face
• B. Weight gain
• C. Joint deformities
• D. Increased hair growth

Correct answer: A

Rationale: The correct answer is A: Butterfly rash on the face. A butterfly-shaped rash across the nose and cheeks is a classic symptom of systemic lupus erythematosus (SLE), an autoimmune disease. Weight gain (Choice B) is not typically associated with SLE. Joint deformities (Choice C) are more commonly seen in conditions like rheumatoid arthritis. Increased hair growth (Choice D) is not a typical finding in SLE.

4. A nurse is caring for a client who has deep vein thrombosis (DVT) of the left lower extremity. Which of the following actions should the nurse take?

• A. Position the client with the affected extremity higher than the heart
• B. Administer acetaminophen for pain
• C. Massage the affected extremity every 4 hours
• D. Withhold heparin IV infusion

Correct answer: D

Rationale: The correct answer is to withhold heparin IV infusion. The nurse should withhold heparin if there are signs of complications, such as bleeding, or if there are contraindications to continuing anticoagulation therapy. Positioning the client with the affected extremity higher than the heart helps reduce swelling and improve blood flow. Administering acetaminophen for pain management can be appropriate, but it is not the priority in this situation. Massaging the affected extremity can dislodge the clot and lead to serious complications, so it should be avoided.

5. 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.

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