Nursing Elites

1. Which of these should not be included when calculating a client's fluid intake?

• A. ice chips
• B. Jell-O™
• C. pudding
• D. IV fluid from an antibiotic piggyback

Correct answer: C

Rationale: Pudding is a semi-solid and does not contribute significantly to fluid intake as it does not melt at room temperature. Therefore, it should not be included in fluid intake calculations. On the other hand, ice chips, Jell-O™, and IV fluid from an antibiotic piggyback are all sources of fluid that can significantly contribute to a client's total fluid intake and should be considered when calculating it. Ice chips and Jell-O™ provide hydration upon melting, while IV fluid directly adds to the fluid volume in the body.

2. Which of the following client statements indicates adequate understanding of preparation for electroencephalography?

• A. "I don't need to eat or drink after midnight."?
• B. "I need to wash my hair before the test."?
• C. "I need to remove metal jewelry."?
• D. "I can't take aspirin before the test."?

Correct answer: B

Rationale: The correct statement is, 'I need to wash my hair before the test.' Washing the hair is necessary to remove hair products that could interfere with electrode attachment to the scalp. Restricting food or drink is not required, except for avoiding caffeinated beverages. Removing metal jewelry is unnecessary for an electroencephalography procedure. Aspirin does not need to be avoided before the test; medications like anticonvulsants, tranquilizers, barbiturates, and sedatives are the ones that might need to be held.

3. The LPN is checking for residual before administering enteral feeding through a PEG tube. Which of these steps is incorrect?

• A. The LPN elevates the head of the bed by at least 30 degrees.
• B. If the residual is greater than 200mL, the LPN should not administer the enteral feeding.
• C. The LPN should discard the residual before administering the tube feeding.
• D. The residual pH level is tested to ensure appropriate placement.

Correct answer: C

Rationale: The incorrect step is choice C. The residual should be discarded before administering the tube feeding. Discarding the residual is essential to prevent contamination and ensure accurate measurement of the enteral feeding. Elevating the head of the bed by at least 30 degrees (choice A) is correct as it helps prevent aspiration during feeding. Testing the pH level of the residual (choice D) ensures proper placement of the tube. Withholding feeding if the residual is greater than 200mL (choice B) is crucial to prevent overfeeding, making this statement correct.

4. All of the following interventions should be performed when fetal heart monitoring indicates fetal distress except:

• A. Increase maternal fluids.
• B. Administer oxygen.
• C. Decrease maternal fluids.
• D. Turn the mother.

Correct answer: C

Rationale: When fetal heart monitoring indicates fetal distress, interventions are aimed at improving oxygenation to the fetus. Increasing maternal fluids helps improve placental perfusion and oxygen delivery to the fetus. Administering oxygen also aids in increasing oxygen supply to the fetus. Turning the mother can help relieve pressure on the vena cava, optimizing blood flow to the placenta. Therefore, decreasing maternal fluids would not be performed as it can further compromise placental perfusion and fetal oxygenation, making it the exception. Decreasing maternal fluids could potentially exacerbate fetal distress by reducing oxygen delivery and nutrient supply to the fetus, which is contrary to the goal of managing fetal distress.

5. The nurse is teaching a client about erythema infectiosum. Which of the following factors is not correct?

• A. There is no rash.
• B. The disorder is uncommon in adults.
• C. There is no fever.
• D. There is sometimes a 'slapped face' appearance.

Correct answer: B

Rationale: The correct answer is B: 'The disorder is uncommon in adults.' Erythema infectiosum, also known as Fifth's disease, is more common in children than in adults. It typically presents with a rash on the face that gives a 'slapped cheek' or 'slapped face' appearance. Fever may be present, and there is a characteristic rash associated with the condition. Therefore, the statement 'The disorder is uncommon in adults' is incorrect, making it the correct answer. The other statements are true regarding erythema infectiosum, making them incorrect choices. There is indeed a rash associated with erythema infectiosum, which can be a prominent feature. Fever may also be present in individuals with this condition. Additionally, the 'slapped face' appearance is a classic characteristic of erythema infectiosum.

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