Nursing Elites

1. A nurse is planning care to prevent complications in a client with immobility. Which of the following interventions should the nurse include?

• A. Massage lower extremities daily to prevent DVT
• B. Remove anti-embolism stockings for 3 hours each day
• C. Limit intake of foods high in calcium to prevent renal calculi
• D. Encourage the client to lie supine to prevent constipation

Correct answer: B

Rationale: The correct answer is B because removing anti-embolism stockings for short periods prevents skin breakdown while ensuring that the stockings remain effective in promoting circulation. Choice A is incorrect because massaging lower extremities daily does not prevent DVT; instead, it may dislodge a clot. Choice C is incorrect as limiting intake of foods high in calcium does not prevent renal calculi; rather, it may help reduce the risk of kidney stones. Choice D is incorrect because encouraging the client to lie supine does not prevent constipation; instead, encouraging mobility and adequate fluid intake can help prevent constipation in immobile clients.

2. A nurse is preparing to administer a measles, mumps, and rubella (MMR) vaccine to an adult client. Which of the following is a contraindication to this vaccine?

• A. The possibility of pregnancy within 4 weeks
• B. Client allergy to strawberry
• C. Client history of genital herpes
• D. The possibility of overseas travel in the next month

Correct answer: A

Rationale: The correct answer is A. The MMR vaccine is contraindicated in pregnant women due to the risk of fetal harm. It is recommended that women avoid becoming pregnant for at least 4 weeks after receiving the vaccine. Choice B, client allergy to strawberry, is not a contraindication for the MMR vaccine. Choice C, client history of genital herpes, is not a contraindication for the MMR vaccine. Choice D, the possibility of overseas travel in the next month, is not a contraindication for the MMR vaccine.

3. A nurse is caring for a client who has breast cancer and has been receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider?

• A. WBC 3,000/mm3
• B. Hemoglobin 14 g/dL
• C. Platelets 250,000/mm3
• D. aPTT 30 seconds

Correct answer: A

Rationale: A WBC count of 3,000/mm3 indicates neutropenia, a dangerous complication of chemotherapy that increases the risk of infection and requires immediate attention. Neutropenia is a common side effect of chemotherapy and can lead to life-threatening infections. Reporting a low WBC count is crucial to ensure timely intervention. Choices B, C, and D are within normal ranges and do not pose immediate risks to the client undergoing chemotherapy.

4. A nurse is preparing to administer a dose of ampicillin. Which of the following actions should the nurse take?

• A. Administer it with food
• B. Check for penicillin allergy
• C. Monitor liver function
• D. Administer it intramuscularly

Correct answer: B

Rationale: The correct answer is to 'Check for penicillin allergy.' Before administering ampicillin, it is crucial to assess the patient for any history of penicillin allergy. This is essential to prevent an adverse allergic reaction, as ampicillin belongs to the penicillin class of antibiotics. Administering ampicillin with food (Choice A) is not a standard requirement and does not impact its effectiveness. Monitoring liver function (Choice C) is not directly related to the immediate pre-administration assessment for ampicillin. Administering ampicillin intramuscularly (Choice D) is not typically the route of administration for this antibiotic, as it is usually given intravenously or orally.

5. A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate via IV infusion. Which of the following findings indicates magnesium toxicity?

• A. Blood glucose of 150 mg/dL
• B. Urine output of 20 mL/hour
• C. Systolic blood pressure of 140 mm Hg
• D. BUN 20 mg/dL

Correct answer: B

Rationale: The correct answer is B. A urine output of 20 mL/hour is a sign of magnesium toxicity because decreased urine output can lead to accumulation of magnesium. Choices A, C, and D are not indicators of magnesium toxicity. Elevated blood glucose, high systolic blood pressure, and normal BUN levels do not specifically point towards magnesium toxicity.

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