Nursing Elites

1. A client who signed an informed consent form for surgery but has since expressed doubts about the need for surgery should discuss concerns with the surgeon to obtain informed answers. Which statement should the nurse make?

• A. It's normal to feel unsure; the surgery will be beneficial
• B. You can cancel surgery any time without any consequences
• C. I'll inform the surgeon to answer your questions before surgery
• D. We can reschedule surgery for another day

Correct answer: C

Rationale: The correct answer is C because the nurse should facilitate communication between the client and the surgeon to address any doubts and provide necessary information. Choice A may invalidate the client's concerns and might not address the root of the issue. Choice B oversimplifies the situation and might not consider the potential consequences of canceling surgery. Choice D, while offering an alternative, does not address the client's doubts about the surgery.

2. A postpartum client with AB negative blood whose newborn is B positive requires what intervention?

• A. Administer Rh immune globulin within 72 hours of delivery
• B. Administer Rh immune globulin at the 6-week postpartum visit
• C. No Rh immune globulin is needed since this is the second pregnancy
• D. Both mother and baby need Rh immune globulin

Correct answer: A

Rationale: The correct intervention is to administer Rh immune globulin within 72 hours of delivery. This is essential to prevent the mother from forming antibodies against Rh-positive blood, which could cause complications in future pregnancies. Choice B is incorrect as the administration should be immediate postpartum. Choice C is incorrect as Rh immune globulin is needed for each Rh-incompatible pregnancy. Choice D is incorrect as only the mother, who is Rh-negative, needs Rh immune globulin.

3. A nurse is teaching a client who has hypertension about dietary modifications to help control blood pressure. Which of the following food choices should the nurse recommend as the best choice for the client to include in their diet?

• A. 1 packet of reconstituted dry onion soup
• B. 3 oz of lean cured ham
• C. 3 oz of chicken breast
• D. 1/2 cup of canned baked beans

Correct answer: C

Rationale: A low sodium diet is recommended for a client who has hypertension. Therefore, the nurse should recommend 3 oz of chicken breast as the best choice for the client's diet because it contains 30 – 90 mg of sodium. Choice A, 1 packet of reconstituted dry onion soup, and Choice B, 3 oz of lean cured ham, are high in sodium content, which is not suitable for a client with hypertension. Choice D, 1/2 cup of canned baked beans, is also high in sodium, making it a less suitable choice compared to 3 oz of chicken breast.

4. A nurse is assessing a newborn following a vaginal delivery. Which of the following findings should the nurse report to the provider?

• A. Vernix caseosa
• B. Head circumference of 34 cm
• C. Jaundice at 24 hours of age
• D. Respiratory rate of 50/min

Correct answer: C

Rationale: Jaundice within the first 24 hours of life is considered pathological and may indicate hemolytic disease or another serious condition, requiring further investigation.

5. A nurse is caring for a client with congestive heart failure. Which of the following prescriptions should the nurse anticipate?

• A. Call the provider if the respiratory rate is less than 18/min
• B. Administer a 500 mL IV bolus of 0.9% sodium chloride over 1 hour
• C. Administer enalapril 2.5 mg PO twice daily
• D. Call the provider if the client’s pulse rate is less than 80/min

Correct answer: C

Rationale: Enalapril, an ACE inhibitor, is commonly prescribed to manage hypertension and heart failure. It helps reduce the workload on the heart and prevent fluid retention. Options A, B, and D are incorrect. Option A focuses on a respiratory rate, which is not specific to heart failure management. Option B suggests administering a large IV bolus of fluid, which can worsen heart failure by increasing fluid volume. Option D addresses the pulse rate, which is not a typical parameter to monitor for heart failure specifically.

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