Nursing Elites

1. A nurse is planning care for a client who has a prescription for knee-length anti-embolic stockings. Which of the following actions should the nurse take?

• A. Remove the client’s stockings at least once during each shift
• B. Roll the top of the client’s stockings down to just below the knee
• C. Seat the client in a chair for 30 minutes prior to applying stockings
• D. Measure the length of the client’s leg from the heel to the gluteal fold

Correct answer: A

Rationale: The correct action for the nurse to take is to remove the client’s stockings at least once during each shift. This is important to inspect the skin and prevent complications such as pressure injuries or impaired circulation. Rolling the top of the stockings down can compromise their effectiveness in preventing blood clots. Seating the client in a chair prior to applying stockings is not directly related to the care of anti-embolic stockings. Measuring the length of the client’s leg from the heel to the gluteal fold is not necessary for the application or care of knee-length anti-embolic stockings.

2. A healthcare professional is caring for a client who has a prescription for a stool specimen to be sent to the laboratory to be tested for ova and parasites. Which of the following instructions regarding specimen collection should the healthcare professional provide to the assistive personnel?

• A. Collect at least 2 inches of formed stool.
• B. Wear sterile gloves while obtaining the specimen.
• C. Use a culturette for specimen collection.
• D. Record the date and time the stool was collected.

Correct answer: A

Rationale: To ensure accurate testing, a minimum amount of stool is required for specimen collection, typically at least 2 inches of formed stool. This amount provides an adequate sample for testing. Wearing sterile gloves is important for infection control but is not specifically required for stool specimen collection. Using a culturette is not typically necessary for collecting stool specimens. Recording the date and time the stool was collected is essential to ensure timely processing but does not directly impact the collection of the specimen itself.

3. The nurse is planning a meal plan that would provide the most iron for a child with anemia. Which dinner menu would be best?

• A. Fish sticks, french fries, banana, cookies, milk
• B. Ground beef patty, lima beans, wheat roll, raisins, milk
• C. Chicken nuggets, macaroni, peas, cantaloupe, milk
• D. Peanut butter and jelly sandwich, apple slices, milk

Correct answer: B

Rationale: The correct answer is B. Ground beef, lima beans, and raisins are rich sources of iron, making this meal plan the most suitable for a child with anemia. Ground beef is a high-iron meat, while lima beans and raisins are also excellent sources of iron. Fish sticks, french fries, banana, and cookies in option A lack sufficient iron content compared to the options in B. Chicken nuggets, macaroni, and peas in option C are not as iron-rich as the ground beef, lima beans, and raisins in option B. Peanut butter and jelly sandwich with apple slices in option D also fall short in providing enough iron when compared to the iron-rich components of option B.

4. A client with a history of coronary artery disease is experiencing chest pain. What is the priority action for the nurse to take?

• A. Administer oxygen via a nasal cannula.
• B. Measure the client's vital signs.
• C. Obtain a 12-lead ECG.
• D. Encourage the client to use pursed-lip breathing.

Correct answer: A

Rationale: Administering oxygen via a nasal cannula is the priority action for a client experiencing chest pain due to coronary artery disease. Oxygen therapy helps improve oxygenation, reduce myocardial workload, and relieve chest pain by increasing oxygen delivery to the heart muscle. While measuring vital signs, obtaining a 12-lead ECG, and encouraging pursed-lip breathing are important interventions, administering oxygen takes precedence in this situation to address the potential hypoxemia associated with chest pain in a client with a history of coronary artery disease.

5. A healthcare professional is reviewing the laboratory values for a client who has a positive Chvostek's sign. Which of the following laboratory findings should the healthcare professional expect?

• A. Decreased calcium
• B. Elevated potassium
• C. Increased sodium
• D. Low hemoglobin

Correct answer: A

Rationale: A positive Chvostek's sign is a clinical indication of low calcium levels, known as hypocalcemia. This sign is elicited by tapping the facial nerve anterior to the ear, resulting in facial muscle twitching. The correct laboratory finding associated with a positive Chvostek's sign is decreased calcium. Elevated potassium (Choice B) is not typically associated with Chvostek's sign but can be seen in conditions like renal failure. Increased sodium (Choice C) is not directly related to Chvostek's sign and is more commonly associated with hypernatremia. Low hemoglobin (Choice D) is not the expected laboratory finding in a client with a positive Chvostek's sign; instead, it suggests anemia, which is unrelated to this clinical manifestation.

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