Nursing Elites

1. Which of these findings would the nurse most closely associate with anemia in a 10-month-old infant?

• A. Hemoglobin level of 12 g/dL
• B. Pale mucosa of the eyelids and lips
• C. Hypoactivity
• D. A heart rate between 140 to 160

Correct answer: B

Rationale: The correct answer is B. Pale mucosa of the eyelids and lips is a classic sign of anemia in infants, indicating a lack of sufficient red blood cells. This finding is due to decreased hemoglobin levels, which causes reduced oxygen delivery to tissues. Choices A, C, and D are less specific to anemia in infants. While a hemoglobin level of 12 g/dL may be within the normal range for a 10-month-old infant, the presence of pale mucosa is a more indicative sign of anemia.

2. The healthcare provider should recognize which of the following as an indication of dehydration in an elderly client?

• A. Skin turgor
• B. Dry mucous membranes
• C. Elevated temperature
• D. Increased pulse pressure

Correct answer: B

Rationale: Dry mucous membranes are a classic sign of dehydration, especially in elderly individuals. Dehydration can lead to decreased moisture in the mucous membranes, making them dry. Skin turgor, although commonly assessed for dehydration in younger individuals, may be less reliable in the elderly due to changes in skin elasticity. Elevated temperature is more indicative of an infection or other conditions. Increased pulse pressure is not typically associated with dehydration in the elderly.

3. Why is it important for the healthcare provider to monitor blood pressure in clients receiving antipsychotic drugs?

• A. Orthostatic hypotension is a common side effect.
• B. Most antipsychotic drugs cause elevated blood pressure.
• C. This provides information on the amount of sodium allowed in the diet.
• D. It will indicate the need to institute anti-parkinsonian drugs.

Correct answer: A

Rationale: The correct answer is A because monitoring for orthostatic hypotension is crucial when clients are receiving antipsychotic drugs since it is a common side effect. Orthostatic hypotension can lead to symptoms like dizziness and falls, making it essential to monitor blood pressure regularly. Choices B, C, and D are incorrect because most antipsychotic drugs do not typically cause elevated blood pressure, monitoring blood pressure is not directly related to the amount of sodium in the diet, and blood pressure monitoring is not primarily used to determine the need for anti-parkinsonian drugs in clients receiving antipsychotic medications.

4. What nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction?

• A. Presence of blood in stools
• B. Oozing liquid stool
• C. Continuous rumbling flatulence
• D. Absence of bowel movements

Correct answer: B

Rationale: The correct answer is B: 'Oozing liquid stool.' In a paralyzed client, oozing liquid stool is a common sign of fecal impaction. This occurrence requires prompt intervention to prevent complications. Choice A, 'Presence of blood in stools,' is more indicative of gastrointestinal bleeding rather than fecal impaction. Choice C, 'Continuous rumbling flatulence,' is associated with gas movement in the intestines and not specifically linked to fecal impaction. Choice D, 'Absence of bowel movements,' could be a sign of constipation but does not directly point towards fecal impaction.

5. A client is receiving total parenteral nutrition (TPN). Which of these interventions should the nurse perform to reduce the risk of infection?

• A. Changing the TPN tubing and solution every 24 hours
• B. Monitoring the TPN infusion rate closely
• C. Keeping the head of the bed elevated
• D. Ensuring the solution is at room temperature before infusing

Correct answer: A

Rationale: The correct answer is to change the TPN tubing and solution every 24 hours to reduce the risk of infection. This practice helps prevent microbial growth and contamination in the TPN solution. Monitoring the infusion rate closely (choice B) is important for preventing metabolic complications but does not directly reduce the risk of infection. Keeping the head of the bed elevated (choice C) is beneficial for preventing aspiration in feeding tube placement but is unrelated to reducing infection risk in TPN. Ensuring the solution is at room temperature before infusing (choice D) is essential for patient comfort and preventing metabolic complications but does not specifically address infection risk reduction.

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