Nursing Elites

1. A nurse is teaching postoperative care to the parents of a toddler following a cleft palate repair. Which of the following should be included in the teaching?

• A. Provide an orthodontic pacifier for comfort
• B. Offer fluids using a straw
• C. Cleanse the suture line with a cotton-tip swab
• D. Remove elbow splints periodically to perform range of motion

Correct answer: D

Rationale: The correct answer is D. Elbow splints are utilized to prevent the child from touching the surgical site. However, it is essential to remove them periodically to conduct range-of-motion exercises to prevent joint stiffness. Choices A, B, and C are incorrect because providing an orthodontic pacifier, offering fluids using a straw, and cleansing the suture line with a cotton-tip swab are not directly related to postoperative care following a cleft palate repair.

2. A nurse is providing education to a client in the first trimester of pregnancy. What information should the nurse include regarding the cause of indigestion and heartburn?

• A. Estrogen causes increased appetite
• B. Progesterone causes relaxation of the cardiac sphincter allowing acid to reflux
• C. HCG hormone leads to increased gastric acidity
• D. The uterus compresses the stomach early in pregnancy

Correct answer: B

Rationale: The correct answer is B. Progesterone causes relaxation of the smooth muscles in the body, including the cardiac sphincter. This relaxation allows stomach acid to reflux into the esophagus, leading to heartburn during pregnancy. Choices A, C, and D are incorrect because they do not directly relate to the physiological mechanism that causes heartburn during pregnancy. Estrogen causing increased appetite (Choice A) is not directly linked to heartburn. HCG hormone increasing gastric acidity (Choice C) is not the primary cause of heartburn during pregnancy. The uterus compressing the stomach early in pregnancy (Choice D) may contribute to feelings of fullness or bloating but is not the main cause of heartburn.

3. A nurse is reviewing the medication metformin with a client who has diabetes. Which of the following side effects should the nurse discuss?

• A. Gastrointestinal upset
• B. Increased appetite
• C. Weight loss
• D. Frequent urination

Correct answer: A

Rationale: The correct answer is A: Gastrointestinal upset. Metformin can cause gastrointestinal upset, especially when first starting therapy. It is important to take it with food to reduce these effects. Increased appetite (choice B) and weight loss (choice C) are not common side effects of metformin but may occur due to improved blood sugar control. Frequent urination (choice D) is a symptom of uncontrolled diabetes and not a side effect of metformin.

4. A client is receiving oxytocin to augment labor. The contractions are occurring every 45 seconds, and the fetal heart rate is 170-180 beats/min. What action should the nurse take?

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

Correct answer: C

Rationale: When contractions occur every 45 seconds with a high fetal heart rate, it indicates uterine hyperstimulation and fetal distress. In this situation, the oxytocin infusion should be discontinued immediately to prevent further complications. Increasing or maintaining the infusion would worsen the hyperstimulation and distress. Decreasing the infusion may not be sufficient to address the current situation and could still lead to complications.

5. A healthcare professional is preparing to administer heparin 8,000 units subcutaneously every eight hrs. The amount available is heparin injection 10,000 units/mL. How many milliliters should the healthcare professional administer per dose?

• A. 0.7 mL
• B. 0.8 mL
• C. 1.0 mL
• D. 1.2 mL

Correct answer: B

Rationale: Calculation: 8000 units / 10,000 units per mL = 0.8 mL. To correctly administer the prescribed dose of 8000 units, the healthcare professional should draw up 0.8 mL from the 10,000 units/mL vial. Options A, C, and D are incorrect as they do not accurately reflect the calculation based on the available concentration of heparin.

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