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. A client with a leg fracture reports increased pain and swelling. What should the nurse suspect?

• A. Compartment syndrome
• B. Deep vein thrombosis
• C. Wound infection
• D. All of the above

Correct answer: A

Rationale: Increased pain and swelling in a fracture could indicate compartment syndrome, a serious condition requiring urgent care. Compartment syndrome is characterized by increased pressure within a muscle compartment, leading to compromised blood flow and potential tissue damage. Deep vein thrombosis is less likely in this scenario as the symptoms are more indicative of compartment syndrome. Wound infection would typically present with localized signs of infection at the wound site, such as redness, warmth, and purulent drainage, rather than diffuse pain and swelling.

3. A client complains of pain at the IV site. Upon assessment, the nurse notes the site is warm, red, and swollen. What is the most likely cause of these findings?

• A. Phlebitis
• B. Infiltration
• C. Allergic reaction
• D. Fluid overload

Correct answer: A

Rationale: The correct answer is A, Phlebitis. Phlebitis is the inflammation of a vein, often caused by irritation from an IV catheter, resulting in warmth, redness, and swelling at the site. Infiltration (choice B) refers to the leaking of IV fluids into the surrounding tissues, causing swelling and pallor, not redness and warmth like in the scenario described. An allergic reaction (choice C) would present with itching, hives, or anaphylaxis, rather than localized warmth, redness, and swelling. Fluid overload (choice D) typically manifests as generalized edema, shortness of breath, and weight gain, not localized symptoms at the IV site.

4. What is the most important action to prevent catheter-associated urinary tract infections (CAUTIs) in a client with an indwelling urinary catheter?

• A. Irrigate the catheter daily.
• B. Change the catheter every 72 hours.
• C. Apply antibiotic ointment at the insertion site.
• D. Ensure the catheter bag is always below bladder level.

Correct answer: D

Rationale: The most crucial action to prevent catheter-associated urinary tract infections (CAUTIs) in a client with an indwelling urinary catheter is to ensure that the catheter bag is always below bladder level. This positioning helps prevent backflow of urine, reducing the risk of CAUTIs. Irrigating the catheter daily (Choice A) is unnecessary and can introduce pathogens. Changing the catheter every 72 hours (Choice B) is not recommended unless clinically indicated to prevent introducing new pathogens. Applying antibiotic ointment at the insertion site (Choice C) is not the most important action to prevent CAUTIs; proper hygiene and maintaining a closed system are more critical.

5. The healthcare provider is providing discharge instructions to a client with chronic heart failure. Which dietary recommendation is most appropriate?

• A. Increase fluid intake.
• B. Follow a low-sodium diet.
• C. Follow a high-protein diet.
• D. Increase sodium intake.

Correct answer: B

Rationale: The most appropriate dietary recommendation for a client with chronic heart failure is to follow a low-sodium diet. This helps manage the condition by reducing fluid retention and the workload on the heart. High fluid intake can lead to fluid overload and exacerbate heart failure symptoms. While protein is important for overall health, a high-protein diet is not specifically indicated for chronic heart failure. Increasing sodium intake is contraindicated in heart failure as it can worsen fluid retention and increase the workload on the heart.

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