Nursing Elites

1. A client describes her cervical mucus as clear, thin, and elastic. Upon examination, the nurse demonstrates that the cervical mucus can be stretched 8-10 cm. The nurse correctly documents the finding as:

• A. increased ferning capacity.
• B. lack of ferning.
• C. spinnbarkheit.
• D. inhospitable.

Correct answer: C

Rationale: The nurse should document the finding as 'spinnbarkheit.' Spinnbarkheit is the term used to describe the clear, thin, and elastic cervical mucus that can be stretched 8-10 cm, indicating ovulation. It helps couples determine the most fertile period for conception. Ferning capacity or crystallization increases as ovulation approaches, but it requires microscopic examination to be confirmed. Lack of ferning cannot be determined without such examination. 'Inhospitable' cervical mucus refers to patterns that prohibit sperm motility, caused by various factors like hormone levels or infection. These conditions cannot be assessed based solely on the description provided in the question.

2. An LPN is reviewing medication lists for several clients recently admitted to the hospital. Which of the following scenarios would be least concerning?

• A. A client taking allopurinol for gout states they have been taking black cohosh to help with post-menopausal symptoms.
• B. A client has an order for warfarin and states they have been taking Ginkgo biloba to improve their memory.
• C. A client taking Lipitor states they have been taking ginseng for an energy boost.
• D. A client has a prescription for an SSRI and states they have been taking St. John's wort to also help with their depression.

Correct answer: C

Rationale: The least concerning scenario is when a client taking Lipitor states they have been taking ginseng for an energy boost. While ginseng may cause an increased risk of bleeding, it should not interact with Lipitor. On the other hand, St. John's wort should not be taken with an SSRI as it may cause serotonin syndrome, posing a more serious concern. Black cohosh should not be taken with allopurinol as they can both cause hepatotoxicity, especially in combination. Ginkgo biloba should not be taken with warfarin as it causes an increased risk of bleeding, making it a more concerning scenario compared to the client taking Lipitor and ginseng.

3. The client has been on vancomycin for three days. Which of the following symptoms is least concerning?

• A. nausea
• B. headache
• C. vertigo
• D. tinnitus

Correct answer: B

Rationale: The correct answer is 'headache.' While vancomycin can cause ototoxicity leading to symptoms like tinnitus, vertigo, and nausea, headaches are not typically associated with vancomycin use. Therefore, headache is the least concerning symptom in this scenario. Nausea, vertigo, and tinnitus are more likely to be related to vancomycin ototoxicity and should be closely monitored and reported. Headache is a common symptom that may not be directly linked to vancomycin use.

4. During a health assessment, a nurse is assisting with gathering subjective data from a client and plans to ask the client about the medical history of the client's extended family. About which family members would the nurse ask the client?

• A. Aunts, uncles, grandparents, and cousins
• B. Foster children and their parents
• C. Wife's children from a previous marriage
• D. Wife and wife's parents

Correct answer: B

Rationale: The correct answer is 'Aunts, uncles, grandparents, and cousins.' When gathering medical history from the client's extended family, it is essential to inquire about relatives beyond the nuclear family, such as aunts, uncles, grandparents, and cousins, as they share genetic and environmental influences. Choice C, 'Wife's children from a previous marriage,' pertains to stepchildren, not extended family members. Choice B, 'Foster children and their parents,' involves individuals who are not biologically related to the client's family. Choice D, 'Wife and wife's parents,' focuses solely on immediate family members and excludes the client's extended family members, which are crucial for a comprehensive health assessment.

5. A nurse is caring for a pregnant client in the labor unit who suddenly experiences spontaneous rupture of the membranes. On inspecting the amniotic fluid, the nurse notes that it is clear, with creamy white flecks. What is the most appropriate action for the nurse to take based on this finding?

• A. Check the client's temperature.
• B. Report the findings to the nurse-midwife.
• C. Obtain a sample of the amniotic fluid for laboratory analysis.
• D. Document the findings.

Correct answer: D

Rationale: Amniotic fluid should be clear and may include bits of vernix, the creamy white fetal skin lubricant. Therefore, the nurse would most appropriately document the findings. Checking the client's temperature, reporting the findings to the nurse-midwife, and obtaining a sample of the amniotic fluid for laboratory analysis are not necessary in this situation. Cloudy, yellow, or foul-smelling amniotic fluid suggests infection, while green fluid indicates that the fetus passed meconium before birth. If abnormalities are noted, the nurse should notify the nurse-midwife.

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