Nursing Elites

1. The nurse is planning care for a 2-year-old child who is scheduled for an infusion of immune globulin for treatment of idiopathic thrombocytopenic purpura (ITP). Which nursing diagnosis has the highest priority for this child?

• A. Risk for infection
• B. Risk for injury
• C. Altered oral mucous membranes
• D. Risk for fluid volume deficit

Correct answer: A

Rationale: The correct answer is 'Risk for infection.' When caring for a child with ITP scheduled for immune globulin infusion, the highest priority is to prevent infection. This is crucial due to the risk of bleeding associated with ITP and the immunosuppression that can be caused by the condition and its treatment. The other options, such as 'Risk for injury,' 'Altered oral mucous membranes,' and 'Risk for fluid volume deficit,' are not as high a priority as preventing infection in this particular situation.

2. A client who is gravida 1, para 0, is admitted to the birthing suite in early labor and requests pain relief. Which action should the nurse implement?

• A. Encourage the client to use distraction techniques
• B. Offer to teach the client relaxation techniques
• C. Determine the client’s pain level and location
• D. Administer an opioid analgesic as prescribed

Correct answer: D

Rationale: In this scenario, the correct action for the nurse to implement is to administer an opioid analgesic as prescribed. Since the client is in early labor and requesting pain relief, opioids are commonly used to provide effective pain relief during labor. Encouraging distraction or teaching relaxation techniques may not be sufficient for pain management during labor, especially in the early stages when the pain intensity can increase rapidly. Determining the pain level and location is important but administering the prescribed opioid is the most appropriate action to address the client's request for pain relief.

3. What assessment technique should the nurse use to monitor a client for a common untoward effect of phenytoin (Dilantin)?

• A. Bladder palpation
• B. Inspection of the mouth
• C. Blood glucose monitoring
• D. Auscultation of breath sounds

Correct answer: B

Rationale: The correct answer is B: Inspection of the mouth. This assessment technique is crucial for monitoring gingival hyperplasia, a common side effect of phenytoin. Bladder palpation (choice A) is not relevant to monitoring for phenytoin's side effects. Blood glucose monitoring (choice C) is important for clients with diabetes but is not specifically related to phenytoin. Auscultation of breath sounds (choice D) is more relevant for assessing respiratory conditions, not side effects of phenytoin.

4. A client receiving amlodipine (Norvasc), a calcium channel blocker, develops 1+ pitting edema around the ankles. It is most important for the nurse to obtain what additional client data?

• A. Bladder distention
• B. Serum albumin level
• C. Abdominal girth
• D. Breath sounds

Correct answer: D

Rationale: The correct answer is 'D. Breath sounds.' When a client receiving amlodipine develops edema, it is crucial to assess for potential heart failure, a side effect of the medication. Checking breath sounds helps in identifying any signs of pulmonary edema, a severe complication of heart failure. Choices A, B, and C are less relevant in this context. Bladder distention could be associated with urinary issues, serum albumin level with malnutrition or liver disease, and abdominal girth with gastrointestinal problems, none of which directly relate to the potential heart failure induced by amlodipine.

5. The nurse-manager of a perinatal unit is notified that one client from the medical-surgical unit needs to be transferred to make room for new admissions. Which client should the nurse recommend for transfer to the antepartal unit?

• A. A 45-year-old with chronic hepatitis B.
• B. A 35-year-old with lupus erythematosus
• C. A 19-year-old diagnosed with rubella
• D. A 25-year-old with herpes lesions of the vulva

Correct answer: B

Rationale: The correct answer is B because a client with lupus erythematosus can be safely transferred to the antepartal unit as this condition does not pose a significant risk to other patients or staff. Choices A, C, and D should not be recommended for transfer to the antepartal unit due to the potential risks they may pose to pregnant women and their unborn babies. Chronic hepatitis B, rubella, and herpes lesions of the vulva can be contagious and harmful in the perinatal setting.

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