Nursing Elites

1. When caring for a laboring client whose contractions are occurring every 2 to 3 min, the nurse should document that the pump is infusing how many ml/hr?

• A. 42
• B. 50
• C. 60
• D. 70

Correct answer: A

Rationale: To calculate the infusion rate, we first need to determine the frequency of contractions per hour. If contractions are occurring every 2 to 3 minutes, this corresponds to 20 to 30 contractions in an hour (60 minutes). The average is 25 contractions in an hour. The pump should be infusing 1 ml for each contraction, so the infusion rate should be 25 ml/hr. Therefore, the correct answer is 42 ml/hr. Choices B, C, and D are incorrect as they do not align with the calculation based on the given data.

2. A child with Leukemia is admitted for chemotherapy, and the nursing diagnosis, altered nutrition, less than body requirements related to anorexia, nausea, vomiting is identified. Which intervention should the nurse include in this child's plan of care?

• A. Allow the child to eat foods desired and tolerated
• B. Restrict foods brought from fast food restaurants
• C. Recommend eating the same foods as siblings eat at home
• D. Encourage a variety of large portions of food at every meal

Correct answer: A

Rationale: The correct intervention for a child with Leukemia undergoing chemotherapy and experiencing altered nutrition, less than body requirements due to anorexia, nausea, and vomiting is to allow the child to eat foods desired and tolerated. This intervention helps improve the child's nutrition intake during chemotherapy. Choice B is incorrect because restricting foods may further limit the child's nutritional intake. Choice C is incorrect because recommending eating the same foods as siblings may not align with the child's preferences or needs during treatment. Choice D is incorrect as encouraging large portions of food at every meal may overwhelm the child and be counterproductive to their nutritional needs.

3. The nurse-manager of a perinatal unit is notified that one client from the medical-surgical unit needs to be transferred to make room for new admissions. Which client should the nurse recommend for transfer to the antepartal unit?

• A. A 45-year-old with chronic hepatitis B.
• B. A 35-year-old with lupus erythematosus
• C. A 19-year-old diagnosed with rubella
• D. A 25-year-old with herpes lesions of the vulva

Correct answer: B

Rationale: The correct answer is B because a client with lupus erythematosus can be safely transferred to the antepartal unit as this condition does not pose a significant risk to other patients or staff. Choices A, C, and D should not be recommended for transfer to the antepartal unit due to the potential risks they may pose to pregnant women and their unborn babies. Chronic hepatitis B, rubella, and herpes lesions of the vulva can be contagious and harmful in the perinatal setting.

4. A client is leaving the hospital against medical advice (AMA) and voluntarily signs the AMA form. Which nursing action is essential prior to the client leaving?

• A. Remove the client's peripheral IV access
• B. Administer requested pain relief medication
• C. Obtain the client's neurological vital signs
• D. Provide the client with the hospital's phone number

Correct answer: A

Rationale: Removing the client's peripheral IV access is essential before the client leaves against medical advice to prevent complications such as infection, thrombosis, or bleeding. Administering pain relief medication (choice B) can be important but not essential at this point. Obtaining neurological vital signs (choice C) is not specifically required before the client leaves. Providing the client with the hospital's phone number (choice D) may be helpful but is not as essential as ensuring the safe removal of IV access.

5. The nurse is caring for a client who is receiving total parenteral nutrition (TPN) via a central venous catheter. Which assessment finding indicates a complication related to the TPN?

• A. Blood glucose level of 180 mg/dl
• B. Serum potassium level of 4.0 mEq/L
• C. Weight gain of 2 pounds in 24 hours
• D. White blood cell count of 7000/mm3

Correct answer: C

Rationale: A weight gain of 2 pounds in 24 hours is concerning as it indicates fluid retention, a potential complication of TPN leading to fluid overload. Elevated blood glucose levels (Choice A) are expected in TPN, serum potassium levels (Choice B) are within the normal range, and a white blood cell count (Choice D) of 7000/mm3 is also normal. Therefore, the correct answer is C, as it suggests a complication related to TPN.

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