Nursing Elites

1. A nurse is planning to administer diltiazem via IV bolus to a client who has 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, a calcium channel blocker, can cause hypotension. Administering diltiazem to a client with hypotension can further lower their blood pressure, leading to adverse effects like dizziness and syncope. Tachycardia (Choice B) is actually a common indication for diltiazem use, as it helps slow down the heart rate in conditions like atrial fibrillation. Decreased level of consciousness (Choice C) may require evaluation but is not a direct contraindication to diltiazem administration. History of diuretic use (Choice D) is not a contraindication to diltiazem, as the two medications can often be safely used together.

2. A nurse is performing a newborn assessment and notes a soft, swollen area on the newborn's scalp that does not cross the suture line. Which of the following should the nurse document?

• A. Cephalohematoma
• B. Caput succedaneum
• C. Subdural hematoma
• D. Molding

Correct answer: A

Rationale: The correct answer is A, cephalohematoma. A cephalohematoma is a collection of blood between the periosteum and the skull that does not cross the suture line. It is caused by trauma during birth and typically resolves on its own. Choice B, caput succedaneum, is characterized by diffuse edema over a newborn's scalp that crosses suture lines. Choice C, subdural hematoma, is a more serious condition involving bleeding between the dura mater and the brain. Choice D, molding, refers to the shaping of the fetal head during passage through the birth canal. Therefore, the nurse should document cephalohematoma in this scenario as it aligns with the description of a soft, swollen area on the newborn's scalp that does not cross the suture line.

3. A nurse is caring for a client who is taking warfarin. The nurse notes that the client has a new prescription for amoxicillin. Which of the following laboratory tests should the nurse monitor closely?

• A. Serum potassium
• B. Prothrombin time (PT)
• C. Serum sodium
• D. Blood glucose

Correct answer: B

Rationale: The correct answer is B: Prothrombin time (PT). Amoxicillin can potentiate the effects of warfarin, increasing the risk of bleeding. Monitoring the prothrombin time (PT) is crucial in this situation to assess the client's clotting ability. Choices A, C, and D are incorrect because amoxicillin's interaction with warfarin does not directly impact serum potassium, serum sodium, or blood glucose levels.

4. A client is prescribed omeprazole. Which of the following should the nurse monitor?

• A. Liver function
• B. Magnesium levels
• C. Blood glucose
• D. Hemoglobin levels

Correct answer: B

Rationale: Corrected Rationale: Omeprazole can cause hypomagnesemia, a condition characterized by low magnesium levels in the blood. Monitoring magnesium levels is crucial to detect and address this potential adverse effect. Liver function (Choice A) is not typically affected by omeprazole. Blood glucose (Choice C) and hemoglobin levels (Choice D) are not directly impacted by omeprazole administration. Therefore, magnesium levels (Choice B) are the most appropriate parameter to monitor in a client prescribed omeprazole.

5. A client with HIV and neutropenia requires specific care from the nurse. Which of the following precautions should the nurse take while caring for this client?

• A. Wear an N95 respirator while caring for the client.
• B. Use a dedicated stethoscope for the client.
• C. Insert an indwelling urinary catheter to monitor urinary output.
• D. Monitor the client’s vital signs every 8 hours.

Correct answer: B

Rationale: Using dedicated equipment for a neutropenic client, such as a stethoscope, helps prevent infections. Neutropenic clients have a weakened immune system, making them vulnerable to infections from common pathogens. Wearing an N95 respirator is not necessary unless airborne precautions are required. Inserting a urinary catheter should be avoided unless necessary to prevent introducing pathogens. Monitoring vital signs should be done more frequently, typically every 4 hours, to promptly identify any changes in the client's condition.

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