Nursing Elites

1. A healthcare provider is assessing a client who has severe dehydration. Which finding indicates effective treatment?

• A. Sunken anterior fontanel
• B. Tenting skin turgor
• C. Flat anterior fontanel
• D. Hyperpnea

Correct answer: C

Rationale: A flat anterior fontanel indicates effective treatment for dehydration in infants. Dehydration often causes sunken fontanels, so when the anterior fontanel becomes flat, it suggests that rehydration has occurred. Sunken anterior fontanel (Choice A) is a sign of dehydration, not effective treatment. Tenting skin turgor (Choice B) is also a sign of dehydration, indicating poor skin turgor. Hyperpnea (Choice D) is increased depth and rate of breathing and is not directly related to the hydration status of the client.

2. A nurse is planning care for a newly admitted adolescent with bacterial meningitis. What intervention should the nurse include?

• A. Initiate droplet precautions
• B. Assist the client to a supine position
• C. Perform a Glasgow Coma Scale every 24 hours
• D. Recommend prophylactic acyclovir for the client's family

Correct answer: A

Rationale: The correct intervention for a newly admitted adolescent with bacterial meningitis is to initiate droplet precautions. Bacterial meningitis is highly contagious, and droplet precautions are necessary to prevent the spread of infection. Assisting the client to a supine position (Choice B) is not directly related to managing bacterial meningitis. Performing a Glasgow Coma Scale every 24 hours (Choice C) may be important to assess the client's neurological status but is not the priority intervention in preventing the spread of infection. Recommending prophylactic acyclovir for the client's family (Choice D) is not a standard practice in the care of a patient with bacterial meningitis.

3. A nurse is caring for a client who is receiving IV diltiazem for atrial fibrillation. Which of the following findings is a contraindication to the administration of diltiazem?

• A. Hypotension
• B. Tachycardia
• C. Decreased level of consciousness
• D. History of diuretic use

Correct answer: A

Rationale: The correct answer is A: Hypotension. Diltiazem can cause further lowering of blood pressure, so it should not be administered if the client is already hypotensive. Monitoring blood pressure is crucial before giving diltiazem. Choice B, tachycardia, is not a contraindication for diltiazem use; in fact, diltiazem is used to slow down the heart rate. Choice C, decreased level of consciousness, may indicate other issues but is not a direct contraindication for diltiazem. Choice D, history of diuretic use, is not a contraindication by itself; however, caution should be exercised when diltiazem is given with diuretics due to potential interactions.

4. A nurse is caring for a client with a stage 2 pressure ulcer. Define the characteristics of the ulcer.

• A. Intact skin with nonblanchable redness (Stage 1)
• B. Full-thickness tissue loss with subQ damage (Stage 3)
• C. Partial-thickness skin loss involving the epidermis and dermis
• D. Full-thickness tissue loss with damage to muscle or bone (Stage 4)

Correct answer: C

Rationale: The correct answer is C. Stage 2 ulcers involve partial-thickness skin loss with visible and superficial damage, which may appear as an abrasion, blister, or shallow crater. Choice A describes a Stage 1 pressure ulcer characterized by intact skin with nonblanchable redness. Choice B describes a Stage 3 pressure ulcer with full-thickness tissue loss and damage to the subcutaneous tissue. Choice D is indicative of a Stage 4 pressure ulcer, involving full-thickness tissue loss with damage extending to muscle or bone.

5. A client is receiving magnesium sulfate for preeclampsia. Which finding indicates magnesium toxicity?

• A. Respiratory rate of 12/min
• B. Diminished deep tendon reflexes
• C. Urine output 40 mL/hr
• D. Systolic blood pressure of 140 mm Hg

Correct answer: B

Rationale: Diminished deep tendon reflexes are a sign of magnesium toxicity. Magnesium sulfate can depress the central nervous system, leading to decreased reflexes. Respiratory rate of 12/min, urine output 40 mL/hr, and systolic blood pressure of 140 mm Hg are not specific findings of magnesium toxicity. Respiratory depression, oliguria, and hypotension are more concerning signs that require immediate attention.

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