Nursing Elites

1. A client who is 38 weeks pregnant with herpes simplex virus is admitted to labor and delivery. What question should the nurse ask?

• A. Do you have any active lesions?
• B. Have your membranes ruptured?
• C. How far apart are your contractions?
• D. Are you positive for beta strep?

Correct answer: A

Rationale: The correct question the nurse should ask the client who is 38 weeks pregnant with herpes simplex virus is 'Do you have any active lesions?' This is crucial because active herpes lesions may necessitate a cesarean delivery to prevent neonatal infection. Choice B, 'Have your membranes ruptured?' is related to assessing for the rupture of membranes, not specific to the client's herpes infection. Choice C, 'How far apart are your contractions?' is related to monitoring labor progress. Choice D, 'Are you positive for beta strep?' is related to group B streptococcus screening, which is important but not the priority in this scenario.

2. A healthcare professional is preparing to administer an IM injection to a 4-month-old infant. Which of the following injection sites should the healthcare professional use?

• A. Ventrogluteal
• B. Deltoid
• C. Dorsogluteal
• D. Vastus lateralis

Correct answer: D

Rationale: The vastus lateralis is the preferred site for IM injections in infants under 1 year of age because it is well developed and easily accessible compared to other muscle groups. The ventrogluteal and deltoid sites are not typically used for infants due to muscle development and size. The dorsogluteal site is not recommended for infants or young children due to its proximity to major nerves and blood vessels.

3. A healthcare provider is reviewing laboratory values for a client who reports fatigue and cold intolerance. The client has an increased thyroid-stimulating hormone (TSH) level and a decreased total T3 and T4 level. The healthcare provider should anticipate a prescription for which of the following medications?

• A. Methimazole
• B. Somatropin
• C. Levothyroxine
• D. Propylthiouracil

Correct answer: C

Rationale: The client’s symptoms and lab results indicate hypothyroidism, and levothyroxine is the standard treatment to replace the deficient thyroid hormones. Methimazole and propylthiouracil are used to treat hyperthyroidism by decreasing the production of thyroid hormones. Somatropin is a growth hormone used in conditions of growth hormone deficiency, not for hypothyroidism.

4. A nurse is assessing a client who has a femur fracture and is in skeletal traction. Which of the following findings should the nurse report to the provider?

• A. Clear fluid drainage from the pin sites
• B. Client reporting intermittent muscle spasms
• C. Client reporting severe pain despite receiving analgesics
• D. The traction weights are hanging freely

Correct answer: C

Rationale: The correct answer is C. Severe pain that is not relieved by analgesics may indicate neurovascular compromise or other complications and requires immediate attention by the provider. Choices A, B, and D are incorrect because clear fluid drainage from the pin sites is expected in skeletal traction, intermittent muscle spasms are common in this situation, and traction weights hanging freely indicate proper traction alignment.

5. A nurse is caring for a client who is 38 weeks pregnant and has a history of herpes simplex virus 2. Which question is most appropriate for the nurse to ask?

• A. Have your membranes ruptured?
• B. How far apart are your contractions?
• C. Do you have any active lesions?
• D. Are you positive for beta strep?

Correct answer: C

Rationale: The most appropriate question for the nurse to ask is whether the client has any active herpes lesions. This is crucial because the presence of active lesions can necessitate a cesarean section to prevent transmission of the virus to the newborn. Asking about membrane rupture (choice A) is important but not directly related to the client's herpes simplex virus 2 status. Inquiring about the frequency of contractions (choice B) is relevant for assessing labor progression but does not address the immediate concern of herpes transmission. Asking about being positive for beta strep (choice D) is important for determining the need for prophylactic antibiotics during labor, but it is not directly related to the client's herpes simplex virus 2 status.

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