Nursing Elites

1. While taking the vital signs of a pregnant client admitted to the labor unit, a nurse notes a temperature of 100.6�F, pulse rate of 100 beats/min, and respirations of 24 breaths/min. What is the most appropriate nursing action based on these findings?

• A. Notify the registered nurse of the findings.
• B. Document the findings in the client's medical record.
• C. Recheck the vital signs in 1 hour.
• D. Continue collecting subjective and objective data.

Correct answer: A

Rationale: The correct answer is to notify the registered nurse of the findings. In a pregnant client, the normal temperature range is 98�F to 99.6�F, with a pulse rate of 60 to 90 beats/min and respirations of 12 to 20 breaths/min. A temperature of 100.4�F or higher, along with an increased pulse rate and faster respirations, suggests a possible infection. Immediate notification of the registered nurse is crucial for further evaluation and intervention. While documenting the findings is essential, the priority lies in promptly escalating abnormal vital signs for assessment and management. Rechecking vital signs in 1 hour may delay necessary interventions for a deteriorating condition. Continuing to collect data is relevant but should not delay informing the registered nurse when abnormal vital signs are present.

2. Which of the following home-care strategies is most likely to negatively impact the body image of a client with Cushing's syndrome?

• A. providing safety measures to prevent falls
• B. taking medications as prescribed
• C. wearing a medical ID indicating Cushing's syndrome
• D. having regular health assessments

Correct answer: C

Rationale: All of the strategies listed are essential components of home care for a client with Cushing's syndrome. However, wearing a medical ID indicating Cushing's syndrome is the correct answer as it can have a negative impact on body image. This choice may constantly remind the client of their condition, potentially affecting their self-image and confidence. On the contrary, providing safety measures to prevent falls (Choice A) would enhance body image by promoting safety and preventing injuries. Taking medications as prescribed (Choice B) is likely to improve body image by managing symptoms effectively. Having regular health assessments (Choice D) demonstrates good self-care and can positively contribute to body image by showing a commitment to maintaining health.

3. The LPN receives a call from a mother caring for her eight-month-old infant. The mother describes that the child has a low-grade fever and has teeth breaking through the gums. Which of the following measures would be inappropriate to recommend to the mother?

• A. Allow the child to chew on a cooled teething ring.
• B. Massage the child's gums gently.
• C. Administer acetaminophen.
• D. Administer aspirin.

Correct answer: D

Rationale: Administering aspirin would be inappropriate in this situation. Aspirin should not be recommended for children due to the increased risk of Reye's syndrome, a serious condition. Choices A, B, and C are all appropriate measures for managing teething discomfort in infants. Allowing the child to chew on a cooled teething ring can help soothe the gums, massaging the child's gums gently can provide relief, and administering acetaminophen is a suitable option for pain relief in infants with teething discomfort. Aspirin is contraindicated in children with viral infections due to the risk of Reye's syndrome, a potentially fatal condition affecting the brain and liver. Therefore, recommending aspirin to the mother would not be appropriate in this case.

4. What is the therapeutic range for carbamazepine (Tegretol)?

• A. 7-12 mcg/mL
• B. 4-10 mcg/mL
• C. 10-14 mcg/mL
• D. 1-5 mcg/mL

Correct answer: B

Rationale: The therapeutic range for carbamazepine (Tegretol) is 4-10 mcg/mL. This range is established based on the optimal balance between effectiveness and safety. Choices A, C, and D are outside the therapeutic range for carbamazepine, which could lead to suboptimal treatment outcomes or increased risk of toxicity. Choice B (4-10 mcg/mL) is the correct range recommended for therapeutic efficacy while minimizing adverse effects.

5. A nurse is reviewing the medical record of an older client with presbycusis. Which finding would the nurse expect to note in the client's record?

• A. Difficulty hearing whispered words in the voice test
• B. Improved hearing ability during conversational speech
• C. Unilateral conductive hearing loss
• D. Difficulty hearing low-pitched tones

Correct answer: A

Rationale: Presbycusis, a sensorineural hearing loss, is the most common form of hearing loss in older adults. Typically, the loss is bilateral, resulting in difficulty hearing high-pitched tones. The condition is revealed when the client has difficulty hearing whispered words in the voice test and consonants during conversational speech. Choice A is correct because it reflects the expected finding in presbycusis. Choices B, C, and D are incorrect because presbycusis does not result in improved hearing ability during conversational speech, unilateral conductive hearing loss, or difficulty hearing low-pitched tones.

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