Nursing Elites

1. The client is assessing a client who has recently found out she is pregnant. Which of the following statements would be a priority for the nurse to follow up on?

• A. "I am nervous about how painful labor will be."?
• B. "I need to review my finances and make sure I am prepared to care for a child."?
• C. "I hate this nausea that I've been having for a week."?
• D. "I am preparing myself to do this on my own because I do not have any family nearby. But I have always been very independent."?

Correct answer: D

Rationale: The nurse should follow up on the client's lack of a support system. Even if there is no family in the area, there are supportive resources in the community that may help the client through the pregnancy and into motherhood. It is normal for the client to worry about labor, address financial concerns, and express displeasure from early pregnancy symptoms such as nausea. However, the priority is to address the client's statement about preparing to handle the pregnancy on her own due to the absence of nearby family support. This could have significant implications for the client's emotional well-being and ability to cope effectively throughout the pregnancy journey.

2. What is the threshold of dextrose concentrations that can safely be administered through a peripheral IV?

• A. Dextrose concentrations below 20% can be safely administered through a peripheral IV; dextrose concentrations above 20% should not be administered through a peripheral IV.
• B. Dextrose concentrations below 5% can be safely administered through a peripheral IV; dextrose concentrations above 5% should not be administered through a peripheral IV.
• C. Dextrose concentrations below 10% can be safely administered through a peripheral IV; dextrose concentrations above 10% should not be administered through a peripheral IV.
• D. Dextrose concentrations above 5% can be safely administered through a peripheral IV; dextrose concentrations below 5% should not be administered through a peripheral IV.

Correct answer: C

Rationale: Dextrose concentrations below 10% are considered safe for administration through a peripheral IV, as concentrations above this threshold can lead to phlebitis, causing inflammation of the vein. Concentrations above 10% should not be administered through a peripheral IV to prevent vein irritation. Choice A is incorrect because concentrations above 20% are too high for a peripheral IV. Choice B is incorrect as dextrose concentrations below 5% are too low to be effective. Choice D is incorrect because the statement is reversed, suggesting that concentrations above 5% are safe, which is not true.

3. When administering a nasal spray medication, what should the client do before the medication is administered?

• A. The client should blow their nose gently before the medication is administered.
• B. The medication should be sprayed into the nostril.
• C. The medication should be administered as the client inhales.
• D. The client should sit upright when the medication is administered.

Correct answer: A

Rationale: The correct answer is that the client should blow their nose gently before the medication is administered. This step helps clear the nasal passages, ensuring that the medication can reach its intended target. Choice B is incorrect as the nasal spray should be directed into the nostril, not just in front of the nose. Administering the medication as the client inhales (Choice C) is crucial to ensure proper delivery, as it helps the medication reach the desired areas. Choice D is incorrect because the client should be sitting upright, not lying flat, when administering nasal spray medication to allow for better absorption and prevent the medication from flowing out.

4. Which of the following foods should be avoided by clients who are prone to developing heartburn as a result of gastroesophageal reflux disease (GERD)?

• A. lettuce
• B. eggs
• C. chocolate
• D. butterscotch

Correct answer: C

Rationale: The correct answer is chocolate. Ingestion of chocolate can reduce lower esophageal sphincter (LES) pressure, leading to reflux and clinical symptoms of GERD. Lettuce, eggs, and butterscotch do not affect LES pressure and are less likely to trigger heartburn in individuals with GERD. Therefore, clients who are prone to developing heartburn due to GERD should avoid consuming chocolate to manage their symptoms effectively.

5. What type of immunity do vaccines provide?

• A. active
• B. passive
• C. transplacental
• D. active and passive

Correct answer: A

Rationale: Vaccines provide active immunity by stimulating the immune system to produce antibodies against specific pathogens. Choice B, passive immunity, is acquired from ready-made antibodies, not through vaccination. Choice C, transplacental immunity, is a form of passive immunity transferred from mother to infant, not acquired through vaccines. Therefore, the correct answer is active immunity.

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