Nursing Elites

1. A healthcare provider is screening patients for various vaccines. Which of the following vaccines is contraindicated during pregnancy?

• A. Diphtheria
• B. Hepatitis B
• C. Mumps
• D. Tetanus

Correct answer: C

Rationale: The correct answer is Mumps. The Mumps vaccine, along with the Rubella vaccine, is contraindicated during pregnancy due to the theoretical risk of affecting the developing fetus. Diphtheria, Hepatitis B, and Tetanus vaccines are considered safe during pregnancy and are often recommended to protect both the pregnant individual and the developing fetus. Therefore, choices A, B, and D are incorrect.

2. Which is an example of a sentinel event?

• A. The terminally ill client is referred to hospice and dies 3 months later.
• B. A client receives an unordered mammogram which reveals a small cyst.
• C. A client with a laceration to the knee requiring 4 sutures falls when getting up unassisted after being instructed to remain in bed.
• D. A client scheduled for knee replacement surgery had an above-the-knee amputation performed.

Correct answer: D

Rationale: Yes! A sentinel event is an unexpected occurrence causing death or serious injury. In this case, a client who was scheduled for knee replacement surgery but had an above-the-knee amputation performed instead represents a sentinel event as it resulted in serious harm that was not intended. The other choices do not meet the criteria for a sentinel event. Choice A describes a natural progression for a terminally ill client, choice B shows an incidental finding from a test, and choice C involves a preventable fall leading to an injury but not a sentinel event.

3. The nurse is caring for a client with cirrhosis of the liver and suspects that the client may be developing hepatic encephalopathy. Which assessment by the nurse suggests that the client is developing this complication?

• A. Asterixis
• B. Hypertension
• C. Kussmaul respirations
• D. Lethargy

Correct answer: A

Rationale: Asterixis, also known as flapping tremors, is a characteristic sign of hepatic encephalopathy. It is a flapping tremor of the hands when the wrists are extended, indicating neurological impairment. Hypertension and Kussmaul respirations are not directly associated with hepatic encephalopathy. Lethargy is a common symptom but not a specific sign that suggests the development of hepatic encephalopathy.

4. A central venous pressure reading of 11cm/H(2)O of an IV of normal saline is determined by the nurse caring for the patient. The patient has a diagnosis of pericarditis. Which of the following is the most applicable?

• A. The patient has a condition of hypovolemia.
• B. Not enough fluid has been given to the patient.
• C. Pericarditis may cause pressures greater than 10cm/H(2)O with testing of CVP.
• D. The patient may have a condition of arteriosclerosis.

Correct answer: C

Rationale: A central venous pressure reading above 10cm/H(2)O may indicate a condition of pericarditis, as the inflammation and fluid accumulation around the heart can lead to elevated pressures. Choices A, B, and D are incorrect. Hypovolemia would typically result in lower CVP readings, not higher. Not enough fluid given would also lead to lower CVP levels. Arteriosclerosis is not directly related to CVP readings in the context of pericarditis.

5. A client is complaining of difficulty walking secondary to a mass in the foot. The nurse should document this finding as:

• A. Plantar fasciitis.
• B. Hallux valgus.
• C. Hammertoe.
• D. Morton's neuroma.

Correct answer: D

Rationale: The correct answer is Morton's neuroma. Morton's neuroma is a small mass or tumor in a digital nerve of the foot, causing pain and difficulty walking. Hallux valgus is commonly known as a bunion, involving a bony bump at the base of the big toe. Hammertoe is a condition where one toe is bent abnormally at the middle joint, resembling a hammer. Plantar fasciitis is characterized by pain and inflammation in the arch of the foot, not by a mass causing difficulty walking. Therefore, options A, B, and C are incorrect as they do not describe a mass in the foot leading to difficulty walking, unlike Morton's neuroma.

Similar Questions