Nursing Elites

1. A client at 20 weeks of gestation is being taught by a nurse about an alpha-fetoprotein (AFP) test. Which of the following information should the nurse include?

• A. This test is used to confirm pregnancy
• B. This test is used to detect neural tube defects
• C. This test will determine the baby's lung maturity
• D. This test will check for gestational diabetes

Correct answer: B

Rationale: The correct answer is B: 'This test is used to detect neural tube defects.' An alpha-fetoprotein test is essential for screening neural tube defects in the fetus, not for confirming pregnancy, determining lung maturity, or checking for gestational diabetes. Detecting neural tube defects is crucial for early intervention and management of potential health issues in the baby.

2. A nurse is maintaining droplet precautions for a client who has meningitis. Which of the following actions should the nurse take?

• A. Wear a gown within 3 feet of the client
• B. Maintain a distance of 6 feet from the client
• C. Wear a surgical mask within 3 feet of the client
• D. Remove gloves before leaving the room

Correct answer: C

Rationale: The correct action for the nurse to take when maintaining droplet precautions for a client with meningitis is to wear a surgical mask within 3 feet of the client. This is essential to prevent the transmission of meningitis via respiratory droplets. Choice A is incorrect because wearing a gown is not specifically required for droplet precautions. Choice B suggests maintaining a distance of 6 feet, which is more applicable to airborne precautions, not droplet precautions. Choice D is incorrect as gloves should be removed and disposed of properly, but it is not related to droplet precautions specifically.

3. What is the best approach to assist a client in performing self-care after an acute myocardial infarction, when the client expresses concern about fatigue?

• A. Provide clear instructions on how to ask for assistance
• B. Gradually resume self-care tasks, focusing on rest periods
• C. Encourage assistive personnel to complete self-care tasks
• D. Encourage the client to remain in bed until fully rested

Correct answer: B

Rationale: The best approach to assist a client in performing self-care after an acute myocardial infarction, especially when the client expresses concern about fatigue, is to gradually resume self-care tasks while focusing on rest periods. This approach allows the client to build confidence in managing their self-care activities while also addressing the issue of fatigue. Choice A is incorrect as it focuses on asking for assistance rather than promoting self-care. Choice C is inappropriate as it suggests delegating the client's self-care tasks to assistive personnel instead of empowering the client. Choice D is incorrect as it can lead to deconditioning and is not conducive to the client's recovery process.

4. A nurse is caring for a client who is scheduled for a bronchoscopy. Which of the following findings should the nurse report to the provider?

• A. The client is anxious about the procedure.
• B. The client has not eaten for 8 hours.
• C. The client has a reported allergy to shellfish.
• D. The client has a platelet count of 100,000/mm³.

Correct answer: D

Rationale: The correct answer is D. A platelet count of 100,000/mm³ is low and increases the risk of bleeding during the bronchoscopy. This finding should be reported to the provider for further evaluation and possible intervention. Choices A, B, and C are not as critical in this situation. Anxiety about the procedure is common and can be managed with appropriate interventions. Not eating for 8 hours is a standard pre-procedure requirement to prevent aspiration during sedation. A reported allergy to shellfish is important to note but is not directly related to the risk of complications during a bronchoscopy.

5. A nurse is caring for a client receiving IV fluids. Which of the following should the nurse do upon noticing phlebitis at the IV site?

• A. Apply a cold compress to the site
• B. Notify the provider immediately
• C. Remove the IV catheter and restart it in another location
• D. Monitor the site for signs of infection

Correct answer: C

Rationale: Upon noticing phlebitis at the IV site, the nurse should remove the IV catheter and restart it in another location. Phlebitis is inflammation of the vein, and leaving the IV catheter in place can lead to further complications such as infection. Applying a cold compress (Choice A) may provide temporary relief but does not address the underlying issue. Notifying the provider immediately (Choice B) is important, but the immediate action to prevent complications is to remove the IV catheter. Monitoring the site for signs of infection (Choice D) is necessary, but the priority action is to remove and reinsert the IV catheter to prevent worsening of the phlebitis.

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