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 client with chronic renal failure needs dietary instructions. Which of the following should the nurse provide?

• A. Increase calcium intake
• B. Provide a diet high in potassium
• C. Restrict protein intake
• D. Increase fluid intake

Correct answer: C

Rationale: The correct answer is to instruct the client to restrict protein intake. In chronic renal failure, the kidneys are unable to effectively filter waste products, so limiting protein helps reduce the buildup of waste in the body. Increasing calcium intake (Choice A) is not typically necessary unless there is a specific deficiency. Providing a diet high in potassium (Choice B) is contraindicated as potassium levels need to be monitored and controlled in renal failure. Increasing fluid intake (Choice D) may be necessary depending on the individual's condition, but restricting protein intake is a more critical dietary instruction for clients with chronic renal failure.

3. What is the name of a legal document that instructs health care providers and family members about what life-sustaining treatment an individual wants if they are unable to make decisions?

• A. Do Not Resuscitate
• B. Informed consent
• C. Living will
• D. Durable power of attorney for health care

Correct answer: C

Rationale: The correct answer is C, 'Living will.' A living will is a legal document that outlines an individual's preferences for life-sustaining medical treatment if they become unable to make decisions. Choice A, 'Do Not Resuscitate,' specifically refers to a directive that instructs healthcare providers not to perform CPR. Choice B, 'Informed consent,' pertains to a patient's right to be informed about and consent to medical treatment. Choice D, 'Durable power of attorney for health care,' involves appointing someone to make healthcare decisions on behalf of an individual when they are unable to do so.

4. A nurse is assessing a 1-hour postpartum client and notes a boggy uterus located 2 cm above the umbilicus. Which of the following actions should the nurse take first?

• A. Take vital signs
• B. Assess lochia
• C. Massage the fundus
• D. Give oxytocin IV bolus

Correct answer: C

Rationale: When a nurse assesses a 1-hour postpartum client with a boggy uterus located 2 cm above the umbilicus, it indicates uterine atony. The first action the nurse should take is to massage the fundus. Fundal massage helps stimulate uterine contractions, which will reduce bleeding and prevent postpartum hemorrhage. Taking vital signs, assessing lochia, or administering an oxytocin IV bolus are important interventions but should come after addressing uterine atony through fundal massage.

5. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following assessment findings requires immediate intervention by the nurse?

• A. Prealbumin level of 20 mg/dL
• B. Weight increase of 2 kg/day
• C. Temperature of 37.6°C
• D. Blood glucose level of 120 mg/dL

Correct answer: B

Rationale: A rapid weight gain of 2 kg/day suggests fluid overload, a possible complication of TPN. This requires immediate intervention to prevent further complications such as pulmonary edema. The other options are not indicative of immediate complications related to TPN. A low prealbumin level may indicate malnutrition but does not require immediate intervention. A slightly elevated temperature and blood glucose level are within normal ranges and do not warrant immediate action.

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