Nursing Elites

1. A client who was normal weight before pregnancy asks about the recommended weight gain during pregnancy. What should the nurse advise?

• A. 18-40 pounds
• B. 25-35 pounds
• C. 11-20 pounds
• D. 15-25 pounds

Correct answer: B

Rationale: The correct answer is B: 25-35 pounds. According to standard prenatal guidelines, a client with a normal pre-pregnancy weight is recommended to gain between 25-35 pounds during pregnancy. This weight gain is important for the overall health of the mother and the developing baby. Choices A, C, and D are incorrect because they do not fall within the recommended weight gain range for a client with a normal pre-pregnancy weight.

2. A client is following Seventh-Day Adventist dietary laws. Which of the following dietary guidelines should the nurse include in the plan of care?

• A. Replace salt with pepper when seasoning food.
• B. Request that coffee is removed from meal trays.
• C. Offer pork with two meals per week.
• D. Provide a high-protein snack between meals.

Correct answer: B

Rationale: Seventh-Day Adventists typically avoid stimulants like caffeine, so requesting that coffee be removed from meal trays is appropriate. Choice A is incorrect because it does not specifically relate to Seventh-Day Adventist dietary guidelines. Choice C is incorrect as pork is generally avoided in Seventh-Day Adventist dietary laws. Choice D is incorrect as it does not address the specific dietary preferences of Seventh-Day Adventist clients.

3. A nurse is caring for a client who is receiving parenteral nutrition. Which of the following findings indicates the therapy is effective?

• A. Client has soft, formed bowel movements.
• B. Client’s mucous membranes are pink.
• C. Client reports ability to complete ADLs.
• D. Client’s blood glucose level is within the expected reference range.

Correct answer: D

Rationale: The correct answer is D because having a blood glucose level within the expected reference range indicates that parenteral nutrition is effectively meeting the client's nutritional needs. Choices A, B, and C are incorrect because soft, formed bowel movements, pink mucous membranes, and the ability to complete activities of daily living do not directly reflect the effectiveness of parenteral nutrition therapy.

4. A nurse is providing teaching to a group of parents of newborns who are planning to formula feed. Which of the following statements by a parent indicates a need for further teaching?

• A. "I will give formula to my baby at room temperature."
• B. "I will ensure my baby's feeds last 10 to 15 minutes."
• C. "I will burp my baby halfway through each feeding."
• D. "I will watch for signs my baby is full and stop the feeding."

Correct answer: B

Rationale: The correct answer is, "I will ensure my baby's feeds last 10 to 15 minutes." This statement indicates a need for further teaching because it suggests a strict time limit for feedings, which may not be appropriate for a newborn. Newborns should be allowed to feed as long as they want, typically around 20-30 minutes per breast if breastfeeding, or on-demand with formula. Choices A, C, and D demonstrate proper feeding practices such as feeding at room temperature, burping halfway through each feeding, and watching for signs of fullness to stop the feeding, which are all appropriate responses by a parent of a formula-fed newborn.

5. The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference between the procedures is:

• A. Percussion uses only one hand, while vibration uses both hands
• B. Percussion delivers cushioned blows to the chest with cupped palms, while vibration gently shakes secretions loose
• C. In both percussion and vibration, the hands are not on top of each other, and hand action is not in tune with the client's breath
• D. Percussion slaps the chest to loosen secretions, while vibration shakes the secretions along with the inhalation

Correct answer: D

Rationale: Chest percussion involves the use of rhythmic tapping to dislodge mucus from the lungs, facilitating its movement toward the larger airways where it can be expelled. This technique is particularly important in conditions where mucus retention is a significant risk factor for infection. The key difference between chest percussion and vibration is that percussion involves slapping the chest to loosen secretions, while vibration involves shaking the secretions along with the inhalation, aiding in moving the loosened secretions upwards for easier removal. Choices A, B, and C do not accurately describe the main difference between chest percussion and vibration, making them incorrect.

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