Nursing Elites

1. The nurse is assessing a client 2 hours postoperatively after a femoral popliteal bypass. The upper leg dressing becomes saturated with blood. The nurse's first action should be to

• A. Wrap the leg with elastic bandages
• B. Apply pressure at the bleeding site
• C. Reinforce the dressing and elevate the leg
• D. Remove the dressings and re-dress the incision

Correct answer: B

Rationale: In this scenario where the upper leg dressing becomes saturated with blood post-femoral popliteal bypass, the nurse's first action should be to apply pressure at the bleeding site. Applying pressure is essential to control hemorrhage and prevent further blood loss. Choice A is incorrect as wrapping the leg with elastic bandages would not address the immediate issue of controlling the bleeding. Choice C is incorrect because reinforcing the dressing and elevating the leg should come after controlling the bleeding. Choice D is incorrect as removing the dressings and re-dressing the incision should only be done after the bleeding is under control to prevent excessive blood loss.

2. The nurse is caring for a client with a new diagnosis of diabetes mellitus. Which of these statements made by the client indicates a need for further teaching?

• A. I will monitor my blood glucose levels regularly and keep a record to show my healthcare provider.
• B. I will follow my meal plan and exercise regularly to help manage my blood sugar levels.
• C. I will stop taking my medications if my blood sugar levels are normal.
• D. I will continue to take my medications even if I feel better.

Correct answer: C

Rationale: Choice C indicates a need for further teaching because stopping medications when blood sugar levels are normal can lead to uncontrolled blood sugar levels if the individual does not understand the importance of medication adherence in managing diabetes. Choices A, B, and D are correct statements that demonstrate good understanding of managing diabetes, such as monitoring blood glucose levels, following a meal plan, exercising regularly, and adhering to medication even when feeling better.

3. A nurse is caring for a new mother who is breastfeeding her term newborn. The newborn weighed 3.4 kg (7.5 lb) at birth and weighs 3.3 kg (7.3 lb) on the second day of life. The mother expresses concern about the weight loss and asks the nurse about the amount of her breast milk. Which of the following responses by the nurse is appropriate?

• A. Why don't you switch to formula to ensure your baby is eating enough?
• B. It is common for new mothers to worry that they are not producing enough milk for their baby.
• C. A healthy newborn can lose 6% of his birth weight before starting to gain weight.
• D. Your newborn will need to remain in the hospital so his weight can be monitored.

Correct answer: C

Rationale: The correct answer is C. A healthy newborn can lose up to 6% of their birth weight within the first few days of life, which is considered normal. This weight loss is usually due to fluid shifts and initial adjustments. Choices A, B, and D are incorrect. Choice A is inappropriate as switching to formula is not necessary at this point. Choice B, while acknowledging the mother's concerns, does not provide factual information about newborn weight loss. Choice D is unnecessary and may cause unnecessary stress to the mother and newborn since monitoring weight loss at home is sufficient unless there are other concerns.

4. After a myocardial infarction, a client is placed on a sodium-restricted diet. When the nurse is teaching the client about the diet, which meal plan would be the most appropriate?

• A. 3 oz. broiled fish, 1 baked potato, 1/2 cup canned beets, 1 orange, and milk
• B. 3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple
• C. A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice
• D. 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange

Correct answer: D

Rationale: The most appropriate meal plan for a client following a myocardial infarction and placed on a sodium-restricted diet should include fresh ingredients with low sodium content to promote heart health. Option D, which consists of 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange, aligns best with these requirements. Option A contains canned beets, which are typically high in sodium. Option B includes canned salmon, which may have added sodium. Option C has a bologna sandwich, which is processed and high in sodium. Therefore, Option D is the most suitable choice for a client needing a low-sodium diet after a heart attack.

5. A client is diagnosed with methicillin-resistant Staphylococcus aureus pneumonia. What type of isolation is most appropriate for this client?

• A. Reverse
• B. Airborne
• C. Standard precautions
• D. Contact

Correct answer: D

Rationale: The correct answer is 'D: Contact.' Contact precautions are necessary for clients with MRSA pneumonia to prevent the spread of the resistant bacteria. MRSA is primarily spread by direct contact, so using contact precautions, such as wearing gloves and gowns, is essential. Choice A, 'Reverse,' is not a type of isolation precaution. Choice B, 'Airborne,' is not the appropriate isolation for MRSA pneumonia, as MRSA is not transmitted through the airborne route. Choice C, 'Standard precautions,' are important for all clients, but for MRSA pneumonia specifically, contact precautions are more targeted and necessary.

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