Nursing Elites

1. The nurse is assessing a first-day postpartum client. Which finding is most indicative of a postpartum infection?

• A. Oral temperature of 100.2°F (37.9°C)
• B. Blood pressure of 122/74 mmHg
• C. Moderate amount of foul-smelling lochia
• D. White blood count of 19,000/mm³ (19x10^9/L SI units)

Correct answer: C

Rationale: A foul-smelling lochia is indicative of a postpartum infection, such as endometritis. Foul-smelling lochia suggests the presence of infection due to the breakdown of tissue by bacteria, leading to the malodor. An oral temperature elevation and an elevated white blood cell count are nonspecific and can be present in various conditions other than postpartum infections, making them less indicative. A blood pressure within normal limits is not typically associated with postpartum infections.

2. In what sequence should the nurse prepare the dose of insulin for a client whose finger stick glucose is 210 mg/dl and is receiving a sliding scale dose of short-acting insulin before breakfast?

• A. Clean the vial's rubber stopper with an alcohol swab, withdraw the correct dose of insulin, and then inject air equal to the insulin dose into the vial.
• B. Inject air equal to the insulin dose into the vial, withdraw the correct dose of insulin, and then clean the vial's rubber stopper with an alcohol swab.
• C. Withdraw the correct dose of insulin, inject air equal to the insulin dose into the vial, and then clean the vial's rubber stopper with an alcohol swab.
• D. Clean the vial's rubber stopper with an alcohol swab, inject air equal to the insulin dose into the vial, and then withdraw the correct dose of insulin.

Correct answer: A

Rationale: The correct sequence for preparing a dose of insulin involves ensuring proper aseptic technique. First, clean the vial's rubber stopper with an alcohol swab to prevent contamination. Second, withdraw the correct dose of insulin to be administered. Lastly, inject air equal to the insulin dose into the vial to maintain proper pressure for withdrawing the medication. This sequence ensures the medication is prepared safely and accurately. Choice A is correct as it follows this sequence. Choices B, C, and D present incorrect sequences that may compromise patient safety by not following the correct aseptic technique. Choice B injects air into the vial before withdrawing insulin, which is incorrect. Choice C reverses the order of withdrawing insulin and injecting air. Choice D withdraws the insulin before injecting air, which can affect the pressure inside the vial and lead to inaccurate dosing.

3. In preparing to administer a scheduled dose of intravenous furosemide (Lasix) to a client with heart failure, the nurse notes that the client’s B-Type Naturetic peptide (BNP) is elevated. What action should the nurse take?

• A. Measure the client’s oxygen saturation before taking further action
• B. Administer a PRN dose of nitroglycerin (Nitrostat)
• C. Administer the dose of furosemide as scheduled
• D. Hold the dose of furosemide until contacting the healthcare provider

Correct answer: D

Rationale: Elevated BNP levels in a client with heart failure may indicate worsening heart failure. Therefore, the correct action for the nurse to take when encountering an elevated BNP before administering furosemide is to hold the dose and contact the healthcare provider for further guidance. This precaution is necessary to ensure the client's safety and prevent potential complications. Options A and B are incorrect as they do not address the issue of the elevated BNP, which is crucial in this situation. Option C is also incorrect because administering furosemide without consulting the healthcare provider could be harmful if the client's condition is deteriorating.

4. A 2-year-old boy with short bowel syndrome has progressed to receiving enteral feedings only. Today his stools are occurring more frequently and have a more liquid consistency. His temperature is 102.2 °F, and he has vomited twice in the past four hours. Which assessment finding indicates that the child is becoming dehydrated?

• A. Occult blood in the stool
• B. Abdominal distention
• C. Elevated urine specific gravity
• D. Hyperactive bowel sounds

Correct answer: C

Rationale: Elevated urine specific gravity indicates concentrated urine, a sign of dehydration. In this scenario, the child is showing signs of dehydration with increased stool frequency, liquid consistency, fever, and vomiting. Occult blood in the stool may indicate gastrointestinal bleeding but is not a specific sign of dehydration. Abdominal distention can be seen in various conditions and is not a specific indicator of dehydration. Hyperactive bowel sounds can be present in various gastrointestinal conditions but are not directly related to dehydration.

5. A client with diabetic peripheral neuropathy has been taking pregabalin for 4 days. Which finding indicates to the nurse that the medication is effective?

• A. Granulating tissue in foot ulcer
• B. Full volume of pedal pulse
• C. Reduced level of pain
• D. Improved visual activity

Correct answer: C

Rationale: The correct answer is C: 'Reduced level of pain.' Pregabalin is used to manage neuropathic pain, so a reduction in pain indicates the medication's effectiveness in this case. Granulating tissue in a foot ulcer and the full volume of a pedal pulse are not direct indicators of pregabalin's effectiveness in managing neuropathic pain. Improved visual activity is not related to the effects of pregabalin in diabetic peripheral neuropathy.

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