Nursing Elites

1. A nurse observes an assistive personnel (AP) providing care to a child who is in skeletal traction. Which of the following actions requires intervention?

• A. Providing a high-protein snack
• B. Assisting the child to reposition
• C. Placing weights on the child’s bed
• D. Massaging pressure points

Correct answer: C

Rationale: The correct answer is C. Placing weights on the child's bed can alter the traction, which must remain constant to be effective. This action requires immediate intervention to prevent harm. Providing a high-protein snack (Choice A) is appropriate for the child's nutritional needs. Assisting the child to reposition (Choice B) helps prevent complications such as pressure ulcers. Massaging pressure points (Choice D) can help promote circulation and prevent skin breakdown. However, altering the traction by placing weights on the bed can be detrimental to the child's condition and must be corrected promptly.

2. 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.

3. A nurse is caring for a client newly prescribed doxazosin mesylate. Which of the following instructions should the nurse include in client education regarding taking the first dose of this medication?

• A. Change positions slowly and lie down if dizziness occurs
• B. There is no need to avoid normal activities
• C. Avoid dairy products while taking this medication
• D. Do not eat green leafy vegetables

Correct answer: A

Rationale: The correct answer is A. Doxazosin can cause first-dose orthostatic hypotension, which may lead to dizziness or fainting when the client stands up too quickly. The nurse should advise the client to change positions slowly and lie down if dizziness occurs to prevent falls and other injuries. Choice B is incorrect because while the client can continue normal activities, caution should be taken with position changes. Choice C is incorrect as doxazosin does not interact with dairy products. Choice D is incorrect as there is no need to avoid green leafy vegetables specifically while taking doxazosin.

4. A nurse is caring for a client who is in labor and has a diagnosis of group B streptococcus ß-hemolytic infection. Which of the following medications should the nurse plan to administer?

• A. Ampicillin
• B. Azithromycin
• C. Ceftriaxone
• D. Acyclovir

Correct answer: A

Rationale: Ampicillin is the correct choice for treating group B streptococcus infections in pregnant women during labor to prevent neonatal infection. Group B streptococcus is commonly treated with penicillin or ampicillin; therefore, choices B, C, and D are incorrect. Azithromycin is not the first-line treatment for group B streptococcus. Ceftriaxone is not the preferred antibiotic for this infection during labor. Acyclovir is an antiviral medication used for herpes simplex virus infections, not bacterial infections like group B streptococcus.

5. A nurse has provided education to a client regarding prescribed levothyroxine sodium. Which of the following client statements demonstrates understanding of medication administration?

• A. I should take the medication in the morning to prevent insomnia.
• B. I can take the medication at night before bed.
• C. I will stop the medication if I start to feel better.
• D. I will take the medication only when I feel symptoms.

Correct answer: A

Rationale: The correct answer is A. Levothyroxine should be taken in the morning on an empty stomach to prevent insomnia and ensure proper absorption of the medication. Choice B is incorrect because taking levothyroxine at night may interfere with sleep and absorption. Choice C is incorrect as stopping the medication without consulting the healthcare provider can lead to negative health outcomes. Choice D is incorrect because levothyroxine is a daily medication that should be taken consistently, not just when symptoms are present.

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