Nursing Elites

1. 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.

2. A nurse should teach which of the following clients requiring crutches about how to use a three-point gait?

• A. A client who is able to bear full weight on both lower extremities.
• B. A client who has bilateral leg braces due to paralysis of the lower extremities.
• C. A client who has a right femur fracture with no weight bearing on the affected leg.
• D. A client who has bilateral knee replacements with partial weight bearing on both legs.

Correct answer: C

Rationale: The correct answer is C because a three-point gait is used when the client can bear full weight on one foot and uses crutches and the uninvolved leg to ambulate. Choices A, B, and D are incorrect because they do not meet the criteria for using a three-point gait. Choice A states that the client can bear full weight on both lower extremities, which does not require a three-point gait. Choice B mentions bilateral leg braces due to paralysis, which would not involve using a three-point gait. Choice D describes a client with bilateral knee replacements with partial weight bearing, which also does not align with the use of a three-point gait.

3. A healthcare provider is assessing a client with chronic obstructive pulmonary disease (COPD) receiving oxygen therapy. Which of the following findings indicates oxygen toxicity?

• A. Oxygen saturation 94%
• B. Decreased respiratory rate
• C. Wheezing
• D. Peripheral cyanosis

Correct answer: B

Rationale: The correct answer is B: Decreased respiratory rate. In clients with COPD, especially when receiving oxygen therapy, a decreased respiratory rate is indicative of oxygen toxicity. This occurs because their respiratory drive is often dependent on low oxygen levels. Oxygen saturation of 94% is within an acceptable range and does not necessarily indicate oxygen toxicity. Wheezing is more commonly associated with airway narrowing or constriction, while peripheral cyanosis is a sign of decreased oxygen levels in the peripheral tissues, not oxygen toxicity.

4. A client newly prescribed sertraline is being taught by a nurse. Which statement by the client indicates understanding?

• A. I should take this medication with meals.
• B. I might have trouble sleeping when I start this medication.
• C. I should avoid drinking orange juice.
• D. I will feel better immediately after starting the medication.

Correct answer: B

Rationale: Choice B, 'I might have trouble sleeping when I start this medication,' indicates understanding because insomnia is a common side effect of sertraline, especially when initiating the medication. This statement shows the client comprehends a potential adverse effect and is prepared for it. Choices A, C, and D are incorrect. Taking sertraline with or without meals does not significantly affect its efficacy. There is no specific contraindication about drinking orange juice while on sertraline. Feeling better immediately after starting the medication is unlikely as sertraline usually takes some time to exert its therapeutic effects.

5. In the nursing process, the evaluation phase is used to determine:

• A. Value of the nursing intervention
• B. Accuracy of problem identification
• C. Quality of the plan of care
• D. Degree of outcome achievement

Correct answer: D

Rationale: The evaluation phase of the nursing process is used to determine the degree of outcome achievement. It assesses whether the goals and outcomes set during the planning phase were met. Choice A is incorrect because it focuses on the worth of the intervention rather than the achievement of outcomes. Choice B is incorrect as it pertains to the assessment phase where problems are identified. Choice C is incorrect as it refers to the planning phase where the care plan is developed, not evaluated.

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