Nursing Elites

1. The nurse observes a nursing assistant performing AM care for a client with a new leg cast. Which action by the assistant will the nurse intervene?

• A. Lifting the affected leg with the palms of the hands
• B. Covering the affected leg with a blanket to avoid chills
• C. Placing plastic over the groin prior to bathing
• D. Elevating the casted leg on two pillows

Correct answer: B

Rationale: The correct answer is to intervene when the assistant covers the affected leg with a blanket to avoid chills. A new cast should not be covered to allow the heat from the cast to evaporate, preventing complications. Lifting the affected leg with the palms of the hands is appropriate for proper handling. Placing plastic over the groin prior to bathing is a standard practice to protect the client's privacy and maintain hygiene. Elevating the casted leg on two pillows helps reduce swelling and promote circulation, making it a suitable action.

2. A client has been taking a drug (Drug A) that is highly metabolized by the cytochrome P-450 system. He has been on this medication for 6 months. At this time, he is started on a second medication (Drug B) that is an inducer of the cytochrome P-450 system. You should monitor this client for:

• A. increased therapeutic effects of Drug A.
• B. increased adverse effects of Drug B.
• C. decreased therapeutic effects of Drug A.
• D. decreased therapeutic effects of Drug B.

Correct answer: C

Rationale: When a client is taking a drug (Drug A) metabolized by the cytochrome P-450 system and is then started on another drug (Drug B) that induces this system, the metabolism of Drug A is increased. This results in decreased therapeutic effects of Drug A as it is broken down more rapidly. Monitoring is required to address potential reduced efficacy. The therapeutic effect of Drug A is diminished, not enhanced. Inducing the cytochrome P-450 system does not directly increase the adverse effects of Drug B. Although Drug B is an inducer, its therapeutic effects are not decreased as it is not metabolized faster.

3. The client is cared for by a nurse and calls for the nurse to come to the room, expressing feeling unwell. The client's vital signs are BP: 130/88, HR: 102, RR: 28. What should the nurse do next?

• A. Administer PRN anxiolytic
• B. Administer Antibiotics
• C. Reassure the client that everything is okay and offer food and beverage
• D. Determine the Glasgow Coma Scale

Correct answer: A

Rationale: Correct! The client's vital signs indicate tachycardia and tachypnea, which could be indicative of hypoxia. Administering a PRN anxiolytic would not address the underlying issue and could mask deterioration. Reassuring the client without further assessment or intervention could lead to a delay in appropriate care if there is a serious underlying cause for the symptoms. Determining the Glasgow Coma Scale is not relevant to the client's presenting symptoms of feeling unwell and suspecting something is wrong, coupled with abnormal vital signs.

4. A woman is in the active phase of labor. An external monitor has been applied, and a fetal heart deceleration of uniform shape is observed, beginning just as the contraction is underway and returning to the baseline at the end of the contraction. Which of the following nursing actions is most appropriate?

• A. Administer O2.
• B. Turn the client on her left side.
• C. Notify the physician.
• D. No action is necessary

Correct answer: D

Rationale: This scenario describes early deceleration due to head compression, which is a benign finding in labor. Early decelerations mirror the contractions and do not require any intervention as they are considered a normal response to fetal head compression. The fetal heart rate returns to baseline at the end of the contraction. In this case, the correct action is no action at the moment. Close monitoring of the mother and baby is essential, but immediate intervention is not required. Administering O2 (Choice A) or turning the client on her left side (Choice B) is not indicated for early decelerations. Notifying the physician (Choice C) is unnecessary for this type of deceleration.

5. A nurse is weighing a breastfed 6-month-old infant who has been brought to the pediatrician's office for a scheduled visit. The infant's weight at birth was 6 lb 8 oz. The nurse notes that the infant now weighs 13 lb. What action should the nurse take?

• A. Tell the mother to decrease the daily number of feedings because the weight gain is excessive.
• B. Tell the mother that the infant's weight is increasing as expected.
• C. Tell the mother that the infant should continue with breast milk as the weight gain is adequate.
• D. Tell the mother that semisolid foods should not be introduced until the infant's weight stabilizes.

Correct answer: B

Rationale: The correct answer is to inform the mother that the infant's weight gain is normal. Infants typically double their birth weight by 6 months, which is precisely the case here, with the infant's weight increasing from 6 lb 8 oz to 13 lb. This weight gain indicates healthy growth and development. Therefore, there is no need to decrease feedings. The infant should continue with breast milk as it is providing adequate nutrition. Additionally, introducing semisolid foods is usually recommended between 4 and 6 months of age, so there is no indication to delay based on the infant's weight gain.

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