Nursing Elites

1. A client who is at 36 weeks of gestation is being taught about nonstress testing. Which of the following statements should the nurse include in the teaching?

• A. This test will determine the length of your cervix.
• B. You will have your blood pressure taken frequently during the test.
• C. You should press the handheld button when you feel your baby move.
• D. This test will take about 5 minutes to complete.

Correct answer: C

Rationale: The correct answer is C. In a nonstress test, the client is required to press a handheld button whenever fetal movement is felt, which is then recorded on the monitor. This action helps assess the baby's heart rate in response to its movements, providing valuable information about the baby's well-being. Choices A, B, and D are incorrect because the nonstress test does not involve determining the length of the cervix, monitoring blood pressure, or being completed in 5 minutes. These aspects are not part of the nonstress testing procedure and are unrelated to the purpose of the test.

2. A nurse is reinforcing discharge teaching with a client who is postoperative following an open radical prostatectomy. Which of the following instructions should the nurse include in the teaching?

• A. Perform Kegel exercises daily
• B. Perform light exercise for 3 hours each day
• C. Avoid bathing for 3 days
• D. Avoid sitting in a chair for more than 2 hours

Correct answer: A

Rationale: The correct answer is A: Perform Kegel exercises daily. After a radical prostatectomy, Kegel exercises are beneficial as they help strengthen the pelvic floor muscles, aiding in urinary control and recovery. Choice B is incorrect because recommending 3 hours of light exercise daily may not be suitable immediately postoperatively. Choice C is incorrect as personal hygiene, including bathing, is important for postoperative care. Choice D is incorrect because sitting for more than 2 hours does not specifically relate to the client's postoperative care needs.

3. A client receiving chemotherapy has developed stomatitis. Which of the following interventions should the nurse implement?

• A. Provide lemon-glycerin swabs
• B. Encourage the client to eat soft foods
• C. Avoid using toothpaste
• D. Instruct the client to use a mouthwash containing alcohol

Correct answer: B

Rationale: The correct intervention for a client with stomatitis is to encourage them to eat soft foods. Soft foods help prevent further irritation of the mouth, making it easier for the client to eat and reducing discomfort. Providing lemon-glycerin swabs could be too harsh on the already irritated mucosa. Avoiding toothpaste is relevant for clients with stomatitis to prevent further irritation. Instructing the client to use a mouthwash containing alcohol is contraindicated as alcohol can further irritate the mucosa.

4. When caring for the client diagnosed with delirium, which condition is the most important for the nurse to investigate?

• A. Cancer of any type
• B. Impaired hearing
• C. Prescription drug intoxication
• D. Heart failure

Correct answer: C

Rationale: When caring for a client diagnosed with delirium, the most important condition for the nurse to investigate is prescription drug intoxication. Delirium in older adults is commonly caused by medication side effects or interactions. Investigating prescription drug intoxication is crucial as it can be a reversible cause of delirium. While cancer, impaired hearing, and heart failure are important considerations in overall care, prescription drug intoxication takes precedence in cases of delirium.

5. How should a healthcare professional assess a patient with chest pain?

• A. Assess the severity of pain and monitor ECG
• B. Administer nitroglycerin and provide oxygen
• C. Administer aspirin and provide pain relief
• D. Monitor for nausea and administer IV fluids

Correct answer: A

Rationale: When assessing a patient with chest pain, the initial step is to assess the severity of pain and monitor the electrocardiogram (ECG) to look for signs of cardiac issues. Administering nitroglycerin and oxygen (Choice B) is a treatment option for suspected cardiac chest pain but should not precede a thorough assessment. Administering aspirin and providing pain relief (Choice C) may be indicated later, but the priority is to assess the situation first. Monitoring for nausea and administering IV fluids (Choice D) is not the initial assessment for chest pain unless there are specific indications present.

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