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. To assess pedal pulses, which arterial sites should the nurse palpate? (Select all that apply)

• A. Posterior tibial artery
• B. Radial artery
• C. External iliac artery
• D. Dorsalis pedis artery

Correct answer: D

Rationale: The correct answer is D: Dorsalis pedis artery. When assessing pedal pulses, the nurse should palpate the dorsalis pedis artery and the posterior tibial artery. The radial artery is located in the wrist and is not a site for assessing pedal pulses. The external iliac artery is not a correct site for assessing pedal pulses in the lower extremities, making it the correct answer.

3. The nurse assigns an unlicensed assistive personnel (UAP) to feed a client who is at risk for aspiration. What action should the nurse take to ensure safety?

• A. Inform the UAP that suction is available at the bedside.
• B. Instruct the UAP to notify the nurse if the client chokes.
• C. Observe the UAP's ability to implement precautions during feeding.
• D. Ask the UAP about previous experience in performing this skill.

Correct answer: C

Rationale: Observing the UAP's ability to implement precautions during feeding is crucial to ensuring the client's safety, especially when there is a risk of aspiration. This hands-on observation allows the nurse to assess whether the UAP is competent in handling the feeding procedure safely. Informing the UAP about suction availability (Choice A) is important but does not directly assess the UAP's ability during feeding. Instructing the UAP to notify the nurse if the client chokes (Choice B) focuses on reactive measures rather than proactive supervision. Asking about previous experience (Choice D) does not provide real-time information on the UAP's current competency in handling the specific feeding task for the at-risk client.

4. What should the nurse prioritize when providing discharge instructions to a client with a new colostomy?

• A. Skin care around the stoma site
• B. The schedule for colostomy bag replacement
• C. Techniques for odor control
• D. Dietary modifications

Correct answer: A

Rationale: Correct answer: Skin care around the stoma site. Proper skin care around the stoma site is crucial for preventing skin irritation and infection, which are common issues for patients with new colostomies. While the schedule for colostomy bag replacement (Option B) is important, it is not the priority during initial discharge instructions. Techniques for odor control (Option C) are relevant but secondary to skin care for a new colostomy. Dietary modifications (Option D) may be discussed later but are not the priority at this stage.

5. A client with a diagnosis of chronic heart failure is prescribed digoxin. What is the most important assessment before administering this medication?

• A. Check blood pressure
• B. Assess heart rate
• C. Monitor respiratory rate
• D. Measure oxygen saturation

Correct answer: B

Rationale: The correct answer is to assess the heart rate before administering digoxin. Digoxin can lead to bradycardia, making it crucial to evaluate the heart rate to prevent potential complications. Checking blood pressure (Choice A) is important but not as critical as assessing the heart rate in this context. Monitoring respiratory rate (Choice C) and measuring oxygen saturation (Choice D) are not the most crucial assessments before administering digoxin, as the primary concern with this medication is its impact on heart rate.

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