Nursing Elites

1. During a routine prenatal visit, a nurse measures a client’s fundal height at 26 weeks gestation. What should the fundal height be?

• A. Approximately 26 cm
• B. Between 24 to 28 cm
• C. Above the umbilicus by two finger widths
• D. Below the xiphoid process

Correct answer: B

Rationale: The correct answer is B: 'Between 24 to 28 cm.' Fundal height is expected to be approximately equal to the weeks of gestation, so at 26 weeks, the fundal height should typically range between 24 to 28 cm. Choice A is incorrect because fundal height is not an exact measurement of gestational age in centimeters. Choice C is incorrect as it provides a general description above the umbilicus, which is not specific to 26 weeks gestation. Choice D is incorrect as the fundal height would not reach below the xiphoid process at 26 weeks gestation.

2. The nurse is preparing to administer a tuberculin skin test (TST). Which area of the body is the preferred site for this injection?

• A. Deltoid muscle
• B. Inner forearm
• C. Abdomen
• D. Thigh

Correct answer: B

Rationale: The inner forearm is the preferred site for administering a tuberculin skin test (TST) due to its easy accessibility, minimal hair interference, and good visibility of the injection site, allowing for accurate interpretation of the test results. The deltoid muscle, abdomen, and thigh are not preferred sites for a TST as they may not provide the optimal conditions required for the test. The deltoid muscle is commonly used for intramuscular injections, the abdomen may have varying subcutaneous fat thickness affecting the test, and the thigh may not provide the necessary visibility for accurate reading.

3. The nurse is providing care for a client with a draining postoperative wound infected with methicillin-resistant Staphylococcus aureus (MRSA). Which is the most important action for the nurse to take?

• A. Encourage increased oral fluids.
• B. Provide high-protein snacks.
• C. Change the wound dressing.
• D. Administer prescribed antibiotics.

Correct answer: D

Rationale: Administering prescribed antibiotics is crucial in treating MRSA infections. MRSA is a type of bacteria that is resistant to many antibiotics, including methicillin. Therefore, prompt administration of the appropriate antibiotics is essential to target the MRSA infection effectively. Encouraging increased oral fluids (Choice A) and providing high-protein snacks (Choice B) may be beneficial for overall recovery but are not the most important actions in treating an MRSA infection. Changing the wound dressing (Choice C) is important for wound care but does not directly address the infection caused by MRSA.

4. When assisting a client to obtain a sputum specimen, the nurse observes the client cough and spit a large amount of frothy saliva in the specimen collection cup. What action should the nurse implement next?

• A. Advise the client that suctioning will be used to obtain another specimen
• B. Re-instruct the client in coughing techniques to obtain another specimen
• C. Provide the client a glass of water and mouthwash to rinse the mouth
• D. Label the container and place the container in a biohazard transport bag

Correct answer: C

Rationale: After observing the client cough and produce frothy saliva in the collection cup, the nurse should provide the client with a glass of water and mouthwash to rinse the mouth. This action helps clear the mouth of contaminants, ensuring a more accurate sputum specimen for diagnostic testing. Option A is incorrect because suctioning is not the appropriate next step in this situation. Option B is unnecessary as re-instructing the client in coughing techniques may not address the immediate issue of contaminated saliva in the specimen. Option D is premature since labeling and transporting the container should only be done after obtaining a valid specimen.

5. During the assessment of a client who has suffered a stroke, what finding would indicate a complication?

• A. Difficulty swallowing
• B. A slight headache
• C. High blood pressure
• D. Muscle weakness on one side

Correct answer: A

Rationale: Difficulty swallowing (dysphagia) can indicate complications such as aspiration risk, which is common after a stroke due to impaired swallowing reflexes. It poses a serious threat to the client's respiratory system. Options B, C, and D are less likely to indicate immediate complications post-stroke. A slight headache is a common complaint and may not necessarily indicate a complication. High blood pressure is a known risk factor for strokes but may not be an immediate post-stroke complication unless it is severely elevated. Muscle weakness on one side is a common sign of stroke but may not directly indicate a new complication.

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