Nursing Elites

1. A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?

• A. Oral mucosa
• B. Conjunctivae
• C. Soles of the feet
• D. Ear lobes

Correct answer: A

Rationale: Central cyanosis is best assessed by examining the oral mucosa, as it is a more reliable indicator compared to other areas like the conjunctivae, soles of the feet, and ear lobes. The oral mucosa reflects the oxygen saturation levels of the blood more accurately. Conjunctivae and ear lobes may show cyanosis, but they are not as reliable as the oral mucosa. The soles of the feet are not typically used to assess central cyanosis.

2. A nurse in a clinic is caring for a client who has a urinary tract infection (UTI). Which of the following prescriptions should the nurse verify with a provider?

• A. Trimethoprim-sulfamethoxazole
• B. Hyoscyamine
• C. Oxybutynin
• D. Phenazopyridine

Correct answer: C

Rationale: The correct answer is C, Oxybutynin. Oxybutynin can worsen urinary retention, so the nurse should verify this prescription with the provider. Trimethoprim-sulfamethoxazole (Choice A) is a common antibiotic used to treat UTIs and does not require verification. Hyoscyamine (Choice B) is an anticholinergic medication used for bladder spasms and does not typically worsen UTI symptoms. Phenazopyridine (Choice D) is a urinary analgesic that helps relieve pain, burning, and discomfort caused by a UTI, which may not necessarily require verification in this scenario.

3. A nurse is caring for a client who is in labor and has an external fetal monitor in place. The nurse observes late decelerations in the fetal heart rate. Which of the following actions should the nurse take first?

• A. Decrease the client's IV fluids
• B. Reposition the client
• C. Administer oxygen by face mask
• D. Document the findings

Correct answer: C

Rationale: Administering oxygen by face mask is the priority intervention when late decelerations are observed in the fetal heart rate. Late decelerations indicate uteroplacental insufficiency, and administering oxygen helps to improve fetal oxygenation. Repositioning the client may also be necessary to relieve pressure on the umbilical cord, but providing oxygen takes precedence to enhance fetal oxygenation. Decreasing IV fluids may not directly address the underlying issue leading to late decelerations. Documenting the findings is important but should not be the first action taken when managing late decelerations.

4. A client who has a new prescription for ferrous sulfate is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should expect dark tarry stools.
• B. I should expect increased bruising.
• C. I will not get as many infections.
• D. I will expect the color of my urine to be amber.

Correct answer: A

Rationale: The correct answer is A. When taking ferrous sulfate, dark tarry stools can occur as a common side effect due to the iron content in the medication. This is a normal response to the medication and not a cause for concern. Choices B, C, and D are incorrect because increased bruising, reduced infections, and amber-colored urine are not expected side effects of ferrous sulfate.

5. A nurse is monitoring an older adult female client who had a myocardial infarction (MI) for the development of an acute kidney injury (AKI). Which of the following findings should the nurse identify as indicating an increased risk of AKI?

• A. Magnesium 2.0 mEq/L
• B. Blood urea nitrogen (BUN) 20 mg/dL
• C. Serum Osmolality 290 mOsm/kg H2O
• D. Serum creatinine 1.8 mg/dL

Correct answer: D

Rationale: An elevated serum creatinine level (1.8 mg/dL) is a significant indicator of potential kidney impairment. In acute kidney injury (AKI), serum creatinine levels rise due to decreased kidney function, reflecting the kidneys' inability to effectively filter waste from the blood. Magnesium level, BUN, and serum osmolality are not direct indicators of kidney function or risk of AKI. Magnesium levels are more related to electrolyte balance, BUN can be affected by factors other than kidney function, and serum osmolality reflects the concentration of solutes in the blood, not specifically kidney function.

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