Nursing Elites

1. The mother of a toddler asks the nurse when she will know that her child is ready to start toilet training. The nurse tells the mother that which observation is a sign of physical readiness?

• A. The child no longer has temper tantrums.
• B. The child can remove his or her own clothing.
• C. The child has been walking for 2 years.
• D. The child can eat using a fork and knife.

Correct answer: B

Rationale: Signs of physical readiness for toilet training include the child's ability to remove his or her own clothing. This ability indicates the child has developed the necessary fine motor skills to manage clothing during toilet training. The other choices are incorrect because temper tantrums, walking for a specific period, and using utensils are not indicators of physical readiness for toilet training.

2. During a health assessment interview, the client tells the nurse that she has some vaginal drainage. The client is concerned that it may indicate a sexually transmitted infection (STI). Which statement should the nurse make to the client?

• A. 'When was your last gynecological checkup?'
• B. 'Have you been engaging in unprotected sexual intercourse?'
• C. Don't worry about the discharge. Some vaginal discharge is normal.'
• D. 'I need some more information about the discharge. What color is it?'

Correct answer: D

Rationale: If the client reports having vaginal drainage and concerns about a possible STI, it is essential for the nurse to gather more information about the discharge. Asking about the color of the discharge helps in determining its characteristics, which can be crucial in identifying potential causes. The color, consistency, odor, and associated symptoms can provide valuable insights into the underlying issue. Statements A and B are relevant questions but not as immediate or specific to addressing the client's concern about the discharge. Statement C dismisses the client's worries and does not encourage further assessment, which is not appropriate in this context.

3. A nurse assisting with data collection of a client gathers both subjective and objective data. Which finding would the nurse document as subjective data?

• A. The client appears anxious.
• B. Blood pressure is 170/80 mm Hg.
• C. The client states that he has a rash.
• D. The client has diminished reflexes in the legs.

Correct answer: C

Rationale: Subjective data are information provided by the client about their symptoms, feelings, or experiences. In this case, the client reporting having a rash is subjective data because it is based on what the client says. Choices A, B, and D involve observations or measurements made by the nurse (anxious appearance, blood pressure, reflexes), which fall under objective data. Objective data are observable and measurable data obtained through physical examination, vital signs assessment, and laboratory tests.

4. Which of the following is least appropriate when caring for a stable postpartum client?

• A. Assess the location and height of the fundus.
• B. Conduct a family assessment, including the mother's future plans for returning to work, if applicable.
• C. Monitor the client for bleeding.
• D. Provide perineal care.

Correct answer: D

Rationale: Providing perineal care is not the least appropriate when caring for a stable postpartum client. Perineal care is essential for maintaining hygiene and preventing infection after delivery. Assessing the location and height of the fundus helps in monitoring postpartum uterine involution, which is crucial for assessing the recovery progress. Conducting a family assessment, including the mother's future plans for returning to work, is important for understanding the support system available for the mother during the postpartum period. Monitoring the client for bleeding is critical to promptly identify and address any postpartum hemorrhage. Therefore, providing perineal care is the least appropriate option among the choices provided as it is a fundamental aspect of postpartum care.

5. Distribution of a drug to various tissues depends on the amount of cardiac output to each type of tissue. Which tissue would receive the highest amount of cardiac output and thus the highest amount of a drug?

• A. skin
• B. adipose tissue
• C. skeletal muscle
• D. myocardium

Correct answer: D

Rationale: The tissue that would receive the highest amount of cardiac output and thus the highest amount of a drug is the myocardium. Highly perfused tissues include vital organs like the brain, heart, kidneys, adrenal glands, and liver. The myocardium, being part of the heart, receives a significant amount of cardiac output. Choices A (skin) and B (adipose tissue) are poorly perfused tissues and would not receive high amounts of cardiac output. Choice C (skeletal muscle) is also less perfused compared to the myocardium.

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