Nursing Elites

1. A nurse is caring for a client who is 24 hr postpartum and is breastfeeding her newborn. The client asks the nurse to warm up seaweed soup that her partner brought for her. Which of the following responses should the nurse make?

• A. Does the doctor know you are eating that?
• B. Why are you eating seaweed soup?
• C. Of course, I will heat that up for you.
• D. The hospital food is more nutritious.

Correct answer: C

Rationale: Respecting cultural preferences and providing client-centered care promotes trust.

2. A nurse is caring for a client who is 4 hours postoperative following an open reduction and internal fixation of the left tibia. Which of the following findings should the nurse report to the provider?

• A. Serous drainage on the dressing
• B. Capillary refill of 2 seconds
• C. Heart rate of 62/min
• D. Left foot is cool to the touch

Correct answer: D

Rationale: The correct answer is D. A cool left foot indicates impaired circulation, which could be a sign of compartment syndrome or impaired blood flow. This finding should be reported to the provider promptly for further evaluation and intervention. Serous drainage on the dressing is expected postoperatively and is not a concerning finding. A capillary refill of 2 seconds is within the normal range (less than 3 seconds is normal), indicating adequate peripheral perfusion. A heart rate of 62/min is also within the normal range for an adult, suggesting no immediate concern related to the surgery.

3. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following laboratory values should the nurse monitor to evaluate the effectiveness of the therapy?

• A. Serum calcium
• B. Blood glucose
• C. Serum protein
• D. Serum albumin

Correct answer: D

Rationale: The correct answer is D, Serum albumin. Serum albumin levels are a good indicator of the nutritional effectiveness of total parenteral nutrition (TPN). Monitoring serum albumin levels helps assess the client's overall protein status and nutritional adequacy. Choices A, B, and C are not direct indicators of the effectiveness of TPN therapy. Serum calcium levels may be affected by other factors, blood glucose monitoring is more relevant for clients with diabetes or those receiving insulin therapy, and serum protein is not as specific as serum albumin in evaluating TPN effectiveness.

4. A client who had a colon resection and a new ascending colostomy is receiving discharge teaching from a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. My stool will become fully formed within 3 weeks.
• B. My skin should be cleaned with alcohol before applying a new pouch.
• C. I should avoid eating popcorn and fresh pineapple.
• D. I should expect bruising around the stoma.

Correct answer: C

Rationale: The correct answer is C because avoiding popcorn and fresh pineapple helps prevent complications with an ascending colostomy. Statements A, B, and D are incorrect. Statement A is inaccurate as it takes time for bowel function to normalize after surgery. Statement B is incorrect as alcohol can be irritating to the skin; gentle soap and water are recommended for cleaning. Statement D is incorrect as bruising around the stoma is not an expected outcome of colostomy creation.

5. A nurse is assessing a client who is in active labor, and the FHR baseline has been 100/min for 15 minutes. What should the nurse suspect?

• A. Maternal fever.
• B. Fetal anemia.
• C. Maternal hypoglycemia.
• D. Chorioamnionitis.

Correct answer: C

Rationale: The correct answer is C: Maternal hypoglycemia. Maternal hypoglycemia can lead to fetal bradycardia, which is indicated by a baseline FHR of 100/min. In this scenario, the sustained low baseline FHR suggests a possible link to maternal hypoglycemia. Maternal fever (Choice A) typically presents with tachycardia rather than bradycardia in the fetus. Fetal anemia (Choice B) usually causes fetal tachycardia as a compensatory mechanism to deliver more oxygen to tissues. Chorioamnionitis (Choice D) is associated with maternal fever and an elevated fetal heart rate, not a sustained low baseline FHR.

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