Nursing Elites

1. A nurse is performing a newborn assessment and notes a soft, swollen area on the newborn's scalp that does not cross the suture line. Which of the following should the nurse document?

• A. Cephalohematoma
• B. Caput succedaneum
• C. Subdural hematoma
• D. Molding

Correct answer: A

Rationale: The correct answer is A, cephalohematoma. A cephalohematoma is a collection of blood between the periosteum and the skull that does not cross the suture line. It is caused by trauma during birth and typically resolves on its own. Choice B, caput succedaneum, is characterized by diffuse edema over a newborn's scalp that crosses suture lines. Choice C, subdural hematoma, is a more serious condition involving bleeding between the dura mater and the brain. Choice D, molding, refers to the shaping of the fetal head during passage through the birth canal. Therefore, the nurse should document cephalohematoma in this scenario as it aligns with the description of a soft, swollen area on the newborn's scalp that does not cross the suture line.

2. A nurse is monitoring a client during an IV urography procedure. Which of the following client reports is the priority finding?

• A. Feeling flushed and warm
• B. Abdominal fullness
• C. Swollen lips
• D. Metallic taste in the mouth

Correct answer: C

Rationale: Swollen lips indicate a potential allergic reaction or anaphylaxis to the contrast dye used during the procedure, which requires immediate medical intervention. Abdominal fullness and metallic taste are common side effects of IV urography and can be managed without urgent intervention. Feeling flushed and warm may also be a common reaction during the procedure and does not indicate a life-threatening situation like an allergic reaction.

3. A nurse is assisting with meal planning for a client who has been prescribed a mechanical soft diet. The nurse should instruct the client to avoid which of the following foods?

• A. Applesauce
• B. Mashed potatoes
• C. Orange slices
• D. Soft bread

Correct answer: C

Rationale: The correct answer is C: Orange slices. Orange slices contain membranes that are difficult to swallow, which can pose a risk to clients on a mechanical soft diet. This type of diet is designed for individuals who have difficulty chewing or swallowing. Choices A, B, and D are suitable for a mechanical soft diet as they are soft in texture and easy to chew and swallow.

4. A nurse is assessing a client who has a sodium level of 122 mEq/L. Which of the following findings should the nurse expect?

• A. Decreased deep tendon reflexes
• B. Positive Trousseau’s sign
• C. Hypoactive bowel sounds
• D. Sticky mucous membranes

Correct answer: A

Rationale: A sodium level of 122 mEq/L indicates hyponatremia, which is characterized by decreased deep tendon reflexes. Hyponatremia leads to neurological symptoms such as altered reflexes. Choices B, C, and D are not typically associated with hyponatremia. Positive Trousseau’s sign is related to hypocalcemia, hypoactive bowel sounds can be seen in paralytic ileus or decreased peristalsis, and sticky mucous membranes are not specific findings related to sodium imbalances.

5. A healthcare provider is reviewing the laboratory data of a client with diabetes mellitus. Which of the following laboratory tests is an indicator of long-term disease management?

• A. Postprandial blood glucose
• B. Glycosylated hemoglobin (HbA1c)
• C. Glucose tolerance test
• D. Fasting blood glucose

Correct answer: B

Rationale: The correct answer is B: Glycosylated hemoglobin (HbA1c). The glycosylated hemoglobin test measures average blood glucose levels over the past 2-3 months, providing an indication of long-term glycemic control in clients with diabetes. Choice A, postprandial blood glucose, reflects blood sugar levels after a meal and does not provide a long-term view. Choice C, glucose tolerance test, evaluates the body's ability to process sugar but does not offer a continuous assessment like the HbA1c test. Choice D, fasting blood glucose, measures blood sugar levels after a period of fasting, which is more indicative of immediate glycemic status rather than long-term management.

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