Nursing Elites

1. A nurse, monitoring a client in the fourth stage of labor, checks the client's vital signs every 15 minutes. The nurse notes that the client's pulse rate has increased from 70 to 100 beats/min. On the basis of this finding, which priority action should the nurse take?

• A. Continuing to check the client's vital signs every 15 minutes
• B. Notifying the registered nurse immediately
• C. Checking the client's uterine fundus
• D. Documenting the vital signs in the client's medical record

Correct answer: C

Rationale: During the fourth stage of labor, the woman's vital signs should be assessed every 15 minutes during the first hour. An increasing pulse rate is an early sign of excessive blood loss, as the heart beats faster to compensate for reduced blood volume. The blood pressure decreases as blood volume diminishes, but this is a later sign of hypovolemia. The most common reason for excessive postpartum bleeding is a uterus that is not firmly contracting and compressing open vessels at the placental site. Therefore, the nurse should check the client's uterine fundus for firmness, height, and positioning. Checking the uterine fundus is the priority action as it helps determine if the client is bleeding excessively. Notifying the registered nurse immediately is not necessary unless the cause of bleeding is unclear and needs further intervention. Continuing to check vital signs without addressing the potential issue will delay necessary intervention. Documenting findings is important, but not the immediate priority when faced with a potential emergency situation like postpartum hemorrhage.

2. Which of the following physical findings indicates that an 11-12-month-old child is at risk for developmental dysplasia of the hip?

• A. refusal to walk
• B. not pulling to a standing position
• C. negative Trendelenburg sign
• D. negative Ortolani sign

Correct answer: B

Rationale: The correct answer is 'not pulling to a standing position.' An 11-12-month-old child not pulling to a standing position may be at risk for developmental dysplasia of the hip. By this age, children typically pull to a standing position, and failure to do so should raise concerns. Refusal to walk is a broader observation and not specific to hip dysplasia. The Trendelenburg sign indicates weakness of the gluteus medius muscle, not hip dysplasia. The Ortolani sign is used to detect congenital subluxation or dislocation of the hip, which is different from developmental dysplasia of the hip.

3. An adult client tells the clinic nurse that he is susceptible to middle ear infections. About which risk factor related to infection of the ears does the nurse question this client?

• A. Loud music
• B. Use of power tools
• C. Occupational noise
• D. Exposure to cigarette smoke

Correct answer: D

Rationale: The correct answer is 'Exposure to cigarette smoke.' Otitis media (middle ear infection) is associated with various factors like colds, allergies, sore throats, and blockage of the eustachian tubes. Risk factors include exposure to cigarette smoke, youth (as otitis media is usually a childhood disease), congenital abnormalities, immune deficiencies, family history of otitis media, recent upper respiratory infections, and allergies. Choices A, B, and C (Loud music, Use of power tools, and Occupational noise) are more likely to cause hearing loss rather than being direct risk factors for middle ear infections.

4. The LPN is caring for a client taking Lipitor (Atorvastatin). Which of these statements would indicate that the client may need reinforced teaching?

• A. "I take my Lipitor with a glass of milk after my breakfast."?
• B. "I take my Lipitor and wait 30 minutes before taking my other medications."?
• C. "I take my Lipitor 30 minutes after I eat something."?
• D. "I take my Lipitor and my other morning medications with my grapefruit juice at breakfast."?

Correct answer: D

Rationale: The correct answer is, 'I take my Lipitor and my other morning medications with my grapefruit juice at breakfast.' This statement indicates a need for reinforced teaching because grapefruit juice should be avoided when taking Lipitor. Grapefruit juice blocks the enzymes needed to break down the drug, which leads to excessive amounts of the drug in the body. Choices A, B, and C show appropriate timing and administration of Lipitor, whereas choice D poses a potential risk due to the interaction between grapefruit juice and Lipitor.

5. When assessing the health-related physical fitness of a client as part of a health assessment, what aspect should be the focus?

• A. agility
• B. speed
• C. body composition
• D. risk factors

Correct answer: D

Rationale: When assessing the health-related physical fitness of a client, the primary focus should be on identifying risk factors that could predispose the client to illness or injury. Risk factors are crucial in determining an individual's overall health status and potential health outcomes. While agility, speed, and body composition are important components of physical fitness assessments, they are not the primary focus when assessing health-related physical fitness from a holistic perspective. Therefore, the correct choice is 'risk factors.'

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