Nursing Elites

1. A nurse working in a pediatric clinic observes the following situations. Which of the following may indicate a delayed child to the nurse?

• A. A 12-month-old that does not 'cruise'.
• B. An 8-month-old that can sit upright unsupported.
• C. A 6-month-old that is rolling prone to supine.
• D. A 3-month-old that does not roll supine to prone.

Correct answer: A

Rationale: The correct answer is 'A 12-month-old that does not 'cruise''. At 12 months, a child should at least be 'cruising' (holding on to objects to walk), which is considered pre-walking. The other choices describe age-appropriate developmental milestones: sitting upright unsupported by 8 months, rolling prone to supine by 6 months, and rolling supine to prone by 3 months. Not 'cruising' at 12 months may indicate a delay in motor skills development.

2. A nurse has been ordered to administer Morphine to a patient. Which of the following effects is unrelated to Morphine's effects on the patient?

• A. Depressed function of the CNS
• B. Increased blood flow
• C. Decreased venous capacity
• D. Pain relief

Correct answer: C

Rationale: Morphine is a narcotic analgesic that acts centrally to relieve pain by binding to opioid receptors in the CNS, leading to the depressed function of the CNS. Morphine also causes peripheral vasodilation, which can lead to increased blood flow. However, morphine causes venous dilation and increased venous capacity rather than decreased venous capacity. Therefore, the effect of 'Decreased venous capacity' is unrelated to Morphine's effects. Pain relief is a well-known effect of Morphine, as it acts on the CNS to alter the perception of pain.

3. A client is admitted to the floor with vomiting and diarrhea for three days. She is receiving IV fluids at 200cc/hr via pump. A priority action for the nurse would be:

• A. Obtaining Intake and Output.
• B. Frequent lung assessments.
• C. Vital signs every shift.
• D. Monitoring the IV site for infiltration.

Correct answer: D

Rationale: In this scenario, the correct priority action for the nurse would be monitoring the IV site for infiltration. The client is receiving IV fluids at a rapid rate, making it crucial to ensure that the IV site is intact and not causing any complications like infiltration, which can lead to tissue damage. While frequent lung assessments are important for detecting signs of fluid overload, in this case, ensuring the IV site's integrity takes precedence. Obtaining Intake and Output is relevant but not the priority over monitoring the IV site. Vital signs are essential, but given the situation, the immediate concern is the IV site's condition to prevent complications.

4. A client has been diagnosed with Disseminated Intravascular Coagulation (DIC) and transferred to the medical intensive care unit (ICU) following an acute bleeding episode. In the ICU, continuous Heparin drip therapy is initiated. Which of the following assessment findings indicates a positive response to Heparin therapy?

• A. increased platelet count
• B. increased fibrinogen
• C. decreased fibrin split products
• D. decreased bleeding

Correct answer: B

Rationale: Effective Heparin therapy should halt the process of intravascular coagulation, leading to increased availability of fibrinogen. Heparin interferes with thrombin-induced conversion of fibrinogen to fibrin. Therefore, an increased fibrinogen level indicates a positive response to Heparin therapy. While increased platelet count and decreased bleeding are positive outcomes, the specific indicator for Heparin therapy response is the increase in fibrinogen level. Decreased fibrin split products would also be a positive response, but an increase in fibrinogen directly reflects the impact of Heparin therapy.

5. A woman is in the active phase of labor. An external monitor has been applied, and a fetal heart deceleration of uniform shape is observed, beginning just as the contraction is underway and returning to the baseline at the end of the contraction. Which of the following nursing actions is most appropriate?

• A. Administer O2 if necessary.
• B. Turn the client on her left side.
• C. Notify the physician.
• D. No action is necessary.

Correct answer: D

Rationale: The correct answer is 'No action is necessary.' In this scenario, the fetal heart deceleration of uniform shape observed is an early deceleration resulting from head compression. Early decelerations are benign and typically do not require any intervention as they mirror the contraction pattern. It is essential to closely observe both the mother and the baby. Administering O2 (Choice A) is not necessary as early decelerations do not indicate fetal distress. Turning the client on her left side (Choice B) is not required for early decelerations. Notifying the physician (Choice C) is not needed for this type of deceleration, as it is a normal response to head compression during labor.

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