Nursing Elites

1. A nurse auscultating the fetal heart rate (FHR) of a pregnant client in the first trimester of pregnancy notes that the FHR is 160 beats/min. With this information, what should be the nurse's next action?

• A. Notify the healthcare provider of the finding.
• B. Document the findings.
• C. Tell the client that the FHR is faster than normal but that it is nothing to be concerned about at this time.
• D. Wait 15 minutes and then recheck the FHR.

Correct answer: B

Rationale: An FHR of 160 beats/min in the first trimester of pregnancy is within the normal range, which is generally 120 to 160 beats/min. The appropriate action for the nurse in this situation is to document the findings. There is no need to notify the healthcare provider as this is a normal finding. Informing the client that the FHR is faster than normal may cause unnecessary anxiety, as it falls within the expected range. Waiting to recheck the FHR is not necessary since the rate is already within the normal range.

2. When a client and their family are facing the end stage of a terminal illness, where might they be best served?

• A. Rehabilitation center.
• B. Extended care facility.
• C. Hospice.
• D. Crisis intervention center.

Correct answer: C

Rationale: When a client and their family are facing the end stage of a terminal illness, they are best served by Hospice. Hospice offers a more humanized alternative care for dying clients compared to hospitals, focusing on comfort and quality of life in the final stages of life. It provides a specialized interdisciplinary team of health care professionals who work together to manage client care. Choices A, B, and D are incorrect because a rehabilitation center focuses on physical therapy, an extended care facility provides long-term care for activities of daily living, and a crisis intervention center deals with immediate psychological or social crises, none of which cater to the specific needs of clients facing the end stage of a terminal illness.

3. During a report from an ER nurse about a client, the nurse identifies a statement that requires additional follow-up. Which of the following statements needs further clarification?

• A. "The client said they have been taking aspirin, but I'm not sure for how long or how much."?
• B. "The client frequently takes antacids, but they have not taken any in the last three days."?
• C. "The client stopped taking ibuprofen after developing gastric ulcers."?
• D. "The client takes Antabuse and has stopped using mouthwash."?

Correct answer: A

Rationale: The correct answer requires further follow-up as the nurse needs to know the duration and dosage of aspirin since it can impact the patient's bleeding risk. Choice B does not require immediate follow-up as not taking antacids for three days is not critical. Choice C indicates a necessary decision made by the client to stop ibuprofen after developing gastric ulcers, hence no immediate follow-up is needed. Choice D provides important information, but the priority is to address the lack of specificity regarding the client's aspirin use, which is crucial for assessing bleeding risk and potential interactions.

4. During a well-baby examination, the nurse measures the head circumference, and it is the same as the chest circumference. On the basis of this measurement, what action should the nurse take?

• A. Document these measurements in the infant's health care record.
• B. Tell the mother that the infant is growing faster than expected.
• C. Suggest to the health care provider that a skull x-ray be performed.
• D. Report the presence of hydrocephalus to the health care provider.

Correct answer: A

Rationale: The head circumference growth rate during the first year is approximately 0.4 inches (1 cm) per month. By 10 to 12 months of age, the infant's head and chest circumferences are equal. In this case, where the head circumference matches the chest circumference, it is a normal finding in infants around 10-12 months. Therefore, the most appropriate action is to document these measurements in the infant's health care record. Suspecting hydrocephalus or suggesting a skull x-ray would be premature and not indicated based on this measurement. Similarly, telling the mother that the infant is growing faster than expected is not accurate and could cause unnecessary concern.

5. A nurse assisting with data collection is preparing to assess the optic nerve. The nurse performs this examination by using which technique?

• A. Assessing visual acuity
• B. Inspecting the eyelids for ptosis
• C. Assessing pupil constriction
• D. Assessing ocular movements

Correct answer: A

Rationale: The correct technique to assess the optic nerve is by testing visual acuity and visual fields through confrontation. Visual acuity involves assessing the clarity of vision, which directly correlates with the function of the optic nerve. Inspecting the eyelids for ptosis is unrelated to optic nerve assessment. Assessing pupil constriction is more related to the assessment of cranial nerves controlling eye movements, particularly the oculomotor nerve. Assessing ocular movements is related to testing the abducens, oculomotor, and trochlear nerves, not specifically the optic nerve.

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