Nursing Elites

1. A rubella titer is performed on a pregnant client, and the results indicate a titer of less than 1:8. The nurse provides the client with which information?

• A. She must have been exposed to the rubella virus at some point in her life.
• B. The test will need to be repeated during the pregnancy.
• C. She has not developed immunity to the rubella virus.
• D. The test results are normal.

Correct answer: B

Rationale: A rubella titer of less than 1:8 indicates that the client is not immune to rubella. In such cases, retesting will be necessary during the pregnancy. If the client is found to be non-immune, rubella immunization is required post-delivery. Therefore, choices A, C, and D are incorrect. Choice A suggests exposure, which cannot be confirmed by the titer result. Choice C wrongly implies that the client has not developed immunity, which is not accurate. Choice D is incorrect as the titer result is not within the normal immune range.

2. The client is assessing a client who has recently found out she is pregnant. Which of the following statements would be a priority for the nurse to follow up on?

• A. "I am nervous about how painful labor will be."?
• B. "I need to review my finances and make sure I am prepared to care for a child."?
• C. "I hate this nausea that I've been having for a week."?
• D. "I am preparing myself to do this on my own because I do not have any family nearby. But I have always been very independent."?

Correct answer: D

Rationale: The nurse should follow up on the client's lack of a support system. Even if there is no family in the area, there are supportive resources in the community that may help the client through the pregnancy and into motherhood. It is normal for the client to worry about labor, address financial concerns, and express displeasure from early pregnancy symptoms such as nausea. However, the priority is to address the client's statement about preparing to handle the pregnancy on her own due to the absence of nearby family support. This could have significant implications for the client's emotional well-being and ability to cope effectively throughout the pregnancy journey.

3. While taking the vital signs of a pregnant client admitted to the labor unit, a nurse notes a temperature of 100.6�F, pulse rate of 100 beats/min, and respirations of 24 breaths/min. What is the most appropriate nursing action based on these findings?

• A. Notify the registered nurse of the findings.
• B. Document the findings in the client's medical record.
• C. Recheck the vital signs in 1 hour.
• D. Continue collecting subjective and objective data.

Correct answer: A

Rationale: The correct answer is to notify the registered nurse of the findings. In a pregnant client, the normal temperature range is 98�F to 99.6�F, with a pulse rate of 60 to 90 beats/min and respirations of 12 to 20 breaths/min. A temperature of 100.4�F or higher, along with an increased pulse rate and faster respirations, suggests a possible infection. Immediate notification of the registered nurse is crucial for further evaluation and intervention. While documenting the findings is essential, the priority lies in promptly escalating abnormal vital signs for assessment and management. Rechecking vital signs in 1 hour may delay necessary interventions for a deteriorating condition. Continuing to collect data is relevant but should not delay informing the registered nurse when abnormal vital signs are present.

4. Assisting with data collection, a nurse notes tenderness while lightly palpating a client's right lower quadrant of the abdomen. The nurse determines that this finding is most likely associated with which anatomic structure?

• A. Liver
• B. Spleen
• C. Pancreas
• D. Appendix

Correct answer: D

Rationale: The correct answer is the Appendix. Tenderness in the right lower quadrant of the abdomen is a classic sign of appendicitis, which is inflammation of the appendix. The appendix is located in the right lower quadrant. The other choices are incorrect. The spleen is located on the posterolateral wall of the abdominal cavity under the diaphragm. The pancreas is located behind the stomach. The liver fills most of the right upper quadrant and extends to the left midclavicular line.

5. How often should a 5-year-old child undergo a dental examination?

• A. Every 6 months
• B. Whenever a new primary tooth erupts
• C. Once a year
• D. Every 3 months

Correct answer: A

Rationale: For a 5-year-old child, dental examinations should be conducted every 6 months. This frequency allows for early detection of dental issues and promotes good oral health. Choices B, C, and D are incorrect because waiting for a new primary tooth to erupt, having an examination once a year, or every 3 months are not the recommended intervals for dental check-ups in this age group. It is essential to adhere to the standard guideline of every 6 months to ensure regular monitoring and preventive care for the child's dental health.

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