Nursing Elites

1. When discussing clients designating a health care proxy in situations requiring a durable power of attorney for health care (DPAHC), what information should the charge nurse include?

• A. The proxy should make health care decisions for the client regardless of the client's ability to do so.
• B. The proxy can make financial decisions if the need arises.
• C. The proxy can make treatment decisions if the client is under anesthesia.
• D. The proxy should manage legal issues for the client.

Correct answer: C

Rationale: The correct answer is C. The charge nurse should include information that the proxy can make treatment decisions if the client is under anesthesia. This is a key function of a durable power of attorney for health care. Choices A, B, and D are incorrect because a health care proxy's role is specifically related to making health care decisions, not financial decisions, legal issues, or decisions made under anesthesia.

2. A nurse in a pediatric clinic is reviewing laboratory findings for a school-age child. Which of the following findings should the nurse report to the provider?

• A. Hgb 12.5 g/dL
• B. Platelets 250,000/mm3
• C. WBC 14,000/mm3
• D. Hct 40%

Correct answer: D

Rationale: The correct answer is D: 'Hct 40%'. An abnormal hematocrit (Hct) level can indicate various conditions such as dehydration, overhydration, or blood disorders, and requires immediate attention from the healthcare provider. Choices A, B, and C are within normal ranges and do not typically warrant immediate provider notification. Hgb 12.5 g/dL (Choice A) is a normal hemoglobin level, Platelets 250,000/mm3 (Choice B) is a normal platelet count, and WBC 14,000/mm3 (Choice C) is slightly elevated but not significantly high to require urgent reporting.

3. A nurse is assessing a client who is receiving continuous enteral feedings through a nasogastric tube. Which of the following findings should the nurse report to the provider?

• A. Gastric residual of 200 mL
• B. Heart rate of 100/min
• C. Urinary output of 250 mL in 12 hr
• D. Blood glucose level of 180 mg/dL

Correct answer: D

Rationale: The correct answer is D. A blood glucose level of 180 mg/dL is higher than expected and should be reported to prevent hyperglycemia complications. High blood glucose levels can lead to hyperglycemia, causing various issues such as increased risk of infection and delayed wound healing. Choices A, B, and C are within normal limits for a client receiving continuous enteral feedings and do not require immediate reporting.

4. A nurse is providing teaching to a client who has a new prescription for ferrous sulfate. Which of the following instructions should the nurse include?

• A. Take this medication with orange juice to increase absorption.
• B. Take this medication on an empty stomach.
• C. Take this medication with milk if it causes stomach upset.
• D. Take this medication at bedtime.

Correct answer: A

Rationale: The correct instruction for a client prescribed ferrous sulfate is to take the medication with orange juice to enhance absorption. Orange juice is recommended because of its vitamin C content, which aids in the absorption of iron. Choice B, taking the medication on an empty stomach, is incorrect because ferrous sulfate is better absorbed with food. Choice C, taking the medication with milk if it causes stomach upset, is incorrect as calcium in milk can interfere with iron absorption. Choice D, taking the medication at bedtime, is incorrect as it is usually recommended to take iron supplements between meals or with food to enhance absorption.

5. A nurse is assessing a client who is in active labor and notes the FHR baseline has been 100/min for the past 15 minutes. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia?

• A. Maternal fever.
• B. Fetal anemia.
• C. Maternal hypoglycemia.
• D. Chorioamnionitis.

Correct answer: C

Rationale: In this scenario, the fetal heart rate (FHR) baseline of 100/min for the past 15 minutes indicates bradycardia. Maternal hypoglycemia can lead to decreased oxygen supply to the fetus, resulting in fetal bradycardia. This situation requires immediate intervention to address the underlying cause. Choices A, B, and D are incorrect as they are not typically associated with fetal bradycardia. Maternal fever, fetal anemia, and chorioamnionitis may have other effects on the fetus but are not primary causes of bradycardia in this context.

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