Nursing Elites

1. A nurse is assessing a client who is 4 hours postpartum. Which of the following findings should the nurse report to the provider?

• A. Lochia that is red and contains small clots.
• B. Fundus firm at the umbilicus.
• C. Fundus deviated to the right.
• D. Moderate perineal pain with swelling.

Correct answer: C

Rationale: The correct answer is C. A fundus that is deviated to the right may indicate a full bladder, which should be addressed postpartum. Choice A is incorrect because red lochia with small clots is expected during the early postpartum period. Choice B is incorrect as the fundus should be firm and midline, not at the umbilicus. Choice D is incorrect as perineal pain and swelling are common postpartum findings that do not require immediate reporting to the provider.

2. What is the initial intervention for a patient with chest pain?

• A. Administer aspirin
• B. Administer nitroglycerin
• C. Provide pain relief
• D. Prepare for surgery

Correct answer: A

Rationale: The correct initial intervention for a patient with chest pain is to administer aspirin. Aspirin helps reduce the risk of clot formation by inhibiting platelet aggregation, which can be beneficial in case the chest pain is due to a cardiac event. Administering nitroglycerin may follow aspirin administration to help relieve chest pain by dilating blood vessels. Providing pain relief is a general approach and may not address the underlying cause of chest pain. Preparing for surgery would not be the initial intervention for chest pain unless there are specific indications for immediate surgical intervention.

3. A nurse is planning care for a client who has a prescription for a bowel-training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care?

• A. Encourage a maximum fluid intake of 1,500 ml per day.
• B. Increase the intake of refined grains in the client's diet.
• C. Provide the client with a cold drink prior to defecation.
• D. Administer a rectal suppository 30 minutes prior to scheduled defecation times.

Correct answer: D

Rationale: Administering a rectal suppository 30 minutes before scheduled defecation times is essential in a bowel-training program following a spinal cord injury. The suppository helps stimulate bowel movements and aids in establishing a regular bowel routine. Encouraging a maximum fluid intake of 1,500 ml per day (Choice A) might be beneficial for bowel function, but it is not specific to the bowel-training program. Increasing the intake of refined grains in the diet (Choice B) is not necessary and could potentially lead to constipation rather than improving bowel movements. Providing a cold drink prior to defecation (Choice C) may not directly contribute to the effectiveness of the bowel-training program compared to the use of a rectal suppository.

4. A nurse is calculating a client's expected date of delivery. The client's last menstrual period began on April 12. Using Nagele's rule, what date should the nurse determine to be the client's expected delivery date?

• A. January 19
• B. 325
• C. 105
• D. 112

Correct answer: A

Rationale: Nagele's rule is a method used to calculate the expected delivery date by subtracting 3 months from the first day of the last menstrual period and adding 7 days. In this case, April 12 minus 3 months is January 12, plus 7 days gives January 19. Therefore, the correct answer is A. Choices B, C, and D do not align with the application of Nagele's rule and are incorrect.

5. A nurse is assessing a client who has hypothyroidism. Which of the following findings should the nurse expect?

• A. Bradycardia
• B. Weight gain
• C. Hypertension
• D. Decreased deep tendon reflexes

Correct answer: D

Rationale: Corrected Rationale: Decreased deep tendon reflexes are a common finding in clients with hypothyroidism due to slowed metabolic processes. The other choices, such as bradycardia (slow heart rate), weight gain, and hypertension (high blood pressure) are not typically associated with hypothyroidism. Bradycardia can occur due to the decreased metabolic rate, but it is not a consistent finding. Weight gain is common but not universal, and hypertension is more commonly associated with hyperthyroidism.

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