Nursing Elites

1. A healthcare provider is assessing a client who is receiving chemotherapy and reports mouth sores. Which of the following findings should the healthcare provider expect?

• A. Dry, cracked lips.
• B. Red, swollen gums.
• C. White patches on the tongue.
• D. Pale, dry mouth.

Correct answer: C

Rationale: White patches on the tongue are a sign of oral candidiasis, a common side effect of chemotherapy. This fungal infection can result in the development of white patches on the tongue. Dry, cracked lips (choice A) are more indicative of dehydration or lack of moisture. Red, swollen gums (choice B) may be a sign of gingivitis or periodontal disease. Pale, dry mouth (choice D) is not typically associated with mouth sores from chemotherapy.

2. A client with heart failure is receiving a continuous IV infusion of milrinone. Which of the following actions should the nurse take?

• A. Monitor the client's blood pressure continuously
• B. Weigh the client daily
• C. Monitor the infusion site for signs of infiltration
• D. Measure the client's intake and output every 2 hours

Correct answer: D

Rationale: Measuring the client's intake and output every 2 hours is essential when caring for a client receiving a continuous IV infusion of milrinone. Milrinone is a medication that affects fluid balance, and monitoring intake and output helps assess the client's response to the medication. Continuous monitoring of blood pressure may not be necessary unless there is a specific indication. While weighing the client daily is important for overall assessment, measuring intake and output more frequently provides more real-time data for fluid balance evaluation. Monitoring the infusion site is crucial for detecting infiltration but is not directly related to managing fluid balance in this situation.

3. A nurse is assessing a newborn who is 1-day old and receiving phototherapy for jaundice. Which action should the nurse take?

• A. Feed the infant glucose water every 2 hours.
• B. Ensure the newborn wears a diaper.
• C. Keep the infant's head covered with a cap.
• D. Apply lotion to the newborn every 4 hours.

Correct answer: C

Rationale: The correct action for the nurse to take is to keep the infant's head covered with a cap. This helps regulate the newborn's body temperature during phototherapy. Option A, feeding the infant glucose water every 2 hours, is incorrect because it is not a standard intervention for newborns receiving phototherapy. Option B, ensuring the newborn wears a diaper, may be necessary for hygiene but is not directly related to phototherapy. Option D, applying lotion to the newborn every 4 hours, is unnecessary and not indicated for managing jaundice or phototherapy.

4. A nurse is assessing a newborn immediately following birth. Which of the following findings should the nurse report to the provider?

• A. Acrocyanosis
• B. Vernix caseosa
• C. A respiratory rate of 50/min
• D. Heart rate of 160/min

Correct answer: D

Rationale: The correct answer is D, a heart rate of 160/min. A heart rate of 160/min in a newborn exceeds the normal range and could indicate potential issues that need further evaluation by the provider. Acrocyanosis (choice A) is a common finding in newborns and is not concerning. Vernix caseosa (choice B) is a white, cheesy substance found on newborn skin and is a normal finding. While a respiratory rate of 50/min (choice C) is slightly elevated, it is not as concerning as a high heart rate in a newborn.

5. A nurse is reviewing the laboratory results of a client who is at 28 weeks of gestation. Which of the following laboratory values should the nurse report to the provider?

• A. Hgb 10 g/dL
• B. Platelets 300,000/mm³
• C. WBC count 12,000/mm³
• D. BUN 18 mg/dL

Correct answer: A

Rationale: The correct answer is A: Hgb 10 g/dL. A hemoglobin level of 10 g/dL is below the normal range for a pregnant client, indicating possible anemia, which is crucial to report during pregnancy to prevent complications for both the mother and the baby. Platelets, WBC count, and BUN levels within the listed values are generally within normal ranges for a pregnant individual at 28 weeks of gestation. Platelets play a role in blood clotting, WBC count helps in fighting infections, and BUN measures kidney function, all of which are typically expected to be within normal limits during pregnancy.

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