Nursing Elites

1. A healthcare provider is reviewing the medical records of a group of older adults (OA). The provider should identify that which of the following is a risk factor that places OA at an increased risk for developing infections?

• A. Improved circulation
• B. Increased immune function
• C. Lowered immune system function
• D. Dehydration

Correct answer: C

Rationale: The correct answer is C: 'Lowered immune system function.' As individuals age, their immune system tends to weaken, making them more susceptible to infections. Choices A, B, and D are incorrect because improved circulation and increased immune function would typically reduce the risk of infections, while dehydration can impact overall health but is not directly related to immune system function in the context of infection risk.

2. A nurse is assessing a client with suspected myocardial infarction. Which finding supports this diagnosis?

• A. Pain radiating to the left arm
• B. Pain relieved by rest
• C. Pain worsening with deep breathing
• D. Pain relieved by antacids

Correct answer: A

Rationale: The correct answer is A. Pain radiating to the left arm is a classic symptom of myocardial infarction, commonly known as a heart attack. This occurs due to the referred pain pathways shared by the heart and the left arm. Choices B, C, and D are incorrect. Pain relieved by rest (choice B) is more indicative of musculoskeletal pain rather than cardiac-related pain. Pain worsening with deep breathing (choice C) is often seen in conditions like pleurisy or pulmonary embolism, not myocardial infarction. Pain relieved by antacids (choice D) suggests gastrointestinal issues like heartburn or acid reflux, not cardiac-related pain.

3. A client is being taught how to use crutches by a nurse. Which of the following instructions should the nurse include?

• A. Place weight on the underarms.
• B. Keep the elbows extended when walking.
• C. Support your weight on your hands.
• D. Hold the crutches 10 cm in front of you when standing.

Correct answer: C

Rationale: The correct answer is C: 'Support your weight on your hands.' When using crutches, it is important to support your weight on your hands rather than underarms to prevent injury to the axillary nerves and blood vessels. Placing weight on the underarms can lead to nerve damage and circulatory issues. Choices A, B, and D are incorrect. Keeping the elbows extended when walking is important for stability, holding the crutches slightly in front of you allows for proper balance, and supporting weight on the hands maintains the correct weight-bearing position.

4. A nurse is caring for a client who is receiving oxytocin IV for augmentation of labor. The client’s contractions are occurring every 45 seconds with a duration of 90 seconds, and the fetal heart rate is 170-180/minute. Which of the following actions should the nurse take?

• A. Discontinue the oxytocin infusion
• B. Increase the oxytocin infusion
• C. Decrease the oxytocin infusion
• D. Maintain the oxytocin infusion

Correct answer: A

Rationale: In this scenario, the contractions are too frequent (tachysystole), and the fetal heart rate is elevated. Tachysystole can lead to decreased oxygen perfusion to the fetus, causing fetal distress. Therefore, the correct action for the nurse to take is to discontinue the oxytocin infusion to prevent harm to both the mother and fetus. Increasing or maintaining the oxytocin infusion would exacerbate the current situation, potentially leading to further complications. Decreasing the oxytocin infusion may not be sufficient to address the tachysystole and elevated fetal heart rate, making it an inappropriate choice.

5. A nurse is teaching a client about the use of aspirin. Which of the following should be included?

• A. It can cause drowsiness
• B. It should be taken with food
• C. Monitor for signs of bleeding
• D. It is safe during pregnancy

Correct answer: C

Rationale: The correct answer is C: 'Monitor for signs of bleeding.' Aspirin is known to increase the risk of bleeding, so clients should be monitored for this potential side effect. Choice A is incorrect because aspirin is not typically associated with causing drowsiness. Choice B is not a specific consideration for aspirin use; it is not necessary to take it with food. Choice D is incorrect because aspirin is not considered safe during pregnancy and should be avoided, especially in the third trimester, as it may cause complications for the mother and the baby.

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