Nursing Elites

1. A client who is at full-term gestation is in active labor and complains of a cramp in her leg. Which intervention should the nurse implement?

• A. Massage the calf and foot
• B. Elevate the leg above the heart
• C. Check the pedal pulse in the affected leg
• D. Extend the leg and flex the foot

Correct answer: D

Rationale: The correct intervention for a client in active labor complaining of a leg cramp is to extend the leg and flex the foot. This action helps stretch the muscles that are cramping, providing relief. Massaging the calf and foot (Choice A) may not be as effective for relieving the cramp. Elevating the leg above the heart (Choice B) is not indicated for a leg cramp. Checking the pedal pulse in the affected leg (Choice C) is unrelated to addressing the leg cramp.

2. While ambulating in the hallway following an appendectomy yesterday, a client complains of chest tightness and shortness of breath. Which action should the nurse implement first?

• A. Administer sublingual nitroglycerin
• B. Assist the client back to the room
• C. Have the client sit down in the hall
• D. Obtain a 12-lead electrocardiogram

Correct answer: C

Rationale: Having the client sit down in the hallway is the first action the nurse should implement. This is crucial to prevent further strain on the heart and to provide a safer environment for assessment and potential emergency intervention. Administering sublingual nitroglycerin (Choice A) may be appropriate later but should not precede ensuring the client's immediate safety. Assisting the client back to the room (Choice B) may not be advisable if the client is experiencing chest tightness and shortness of breath. Obtaining a 12-lead electrocardiogram (Choice D) is important but would not be the initial action to address the client's immediate symptoms.

3. A new mother who is breastfeeding her newborn for the first time after delivery reports nipple pain when the baby sucks. Based on this client problem, which action should the PN take?

• A. Ensure that all the areolar tissue of the nipple is in the infant's mouth
• B. Have the mother reposition the infant from the cradle to the football hold
• C. Check for engorgement and assess the nipples for cracks or lesions
• D. Apply a warm compress to the breast for 10 minutes before each feeding

Correct answer: A

Rationale: Proper latch, including all the areolar tissue in the infant's mouth, is essential to prevent nipple pain and ensure effective breastfeeding. Option A is correct because ensuring that all the areolar tissue of the nipple is in the infant's mouth helps achieve a good latch, reducing nipple pain. Option B is incorrect as repositioning the infant may not address the root cause of the pain related to latch issues. Option C is incorrect because while checking for engorgement and nipple issues is important, it does not directly address the latch concern causing the pain. Option D is incorrect as applying a warm compress is not recommended for breastfeeding mothers; a warm compress can help with pain associated with engorgement, but it does not address latch issues.

4. When caring for a client with colostomy, which topical skin preparation should the PN apply around the stoma?

• A. Antiseptic cream
• B. Petroleum jelly
• C. Cornstarch
• D. Stomadhesive

Correct answer: D

Rationale: The correct answer is 'Stomadhesive.' Stomadhesive is a protective barrier used around the stoma to prevent skin irritation and to secure the colostomy bag. This preparation helps to maintain skin integrity and prevent complications such as skin breakdown. Antiseptic cream (Choice A) is not typically used around the stoma as it can irritate the skin. Petroleum jelly (Choice B) is also not recommended as it can interfere with the adhesive properties of the colostomy appliance. Cornstarch (Choice C) is not suitable for application around the stoma as it can promote moisture and lead to skin irritation.

5. Which type of cell is responsible for producing antibodies in the immune system?

• A. B lymphocytes
• B. T lymphocytes
• C. Macrophages
• D. Neutrophils

Correct answer: A

Rationale: The correct answer is A: B lymphocytes. B lymphocytes (B cells) are a crucial part of the adaptive immune system. They produce antibodies, which are proteins that specifically target and neutralize pathogens such as bacteria and viruses. T lymphocytes (choice B) are involved in cell-mediated immunity rather than antibody production. Macrophages (choice C) are phagocytic cells that engulf and digest pathogens but do not produce antibodies. Neutrophils (choice D) are a type of white blood cell that primarily function in the innate immune response by phagocytosing pathogens.

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