Nursing Elites

1. The nurse is assessing a first-day postpartum client. Which finding is most indicative of a postpartum infection?

• A. Oral temperature of 100.2°F (37.9°C)
• B. Blood pressure of 122/74 mmHg
• C. Moderate amount of foul-smelling lochia
• D. White blood count of 19,000/mm³ (19x10^9/L SI units)

Correct answer: C

Rationale: A foul-smelling lochia is indicative of a postpartum infection, such as endometritis. Foul-smelling lochia suggests the presence of infection due to the breakdown of tissue by bacteria, leading to the malodor. An oral temperature elevation and an elevated white blood cell count are nonspecific and can be present in various conditions other than postpartum infections, making them less indicative. A blood pressure within normal limits is not typically associated with postpartum infections.

2. The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized elderly client with an indwelling urinary catheter every two hours. What additional action should the nurse instruct the UAP to take each time the client is turned?

• A. Empty the urinary drainage bag
• B. Feed the client a snack
• C. Offer the client oral fluids
• D. Assess the breath sounds

Correct answer: A

Rationale: The correct additional action the nurse should instruct the UAP to take each time the immobilized elderly client with an indwelling urinary catheter is turned is to empty the urinary drainage bag. This action helps to prevent backflow of urine, reduces the risk of infection, and prevents bladder distention, which are crucial for the client's comfort and health. Choices B, C, and D are incorrect as they are not directly related to the care of a client with an indwelling urinary catheter. Feeding a snack, offering oral fluids, or assessing breath sounds are important aspects of care but not the immediate action needed when turning a client with an indwelling urinary catheter to prevent complications.

3. The school nurse is screening students for spinal abnormalities and instructs each student to stand up and then touch their toes. Which finding indicates that a student should be referred for scoliosis evaluation?

• A. Inability to touch their toes
• B. Asymmetry of the shoulders when standing upright
• C. Audible crepitus when bending
• D. An exaggerated upper thoracic convex curvature

Correct answer: B

Rationale: Asymmetry of the shoulders when standing upright is a common indicator of scoliosis. This finding suggests a possible spinal abnormality and should prompt further evaluation. Choices A, C, and D are not specific indicators of scoliosis. Inability to touch their toes may indicate flexibility issues or tightness in the hamstrings. Audible crepitus when bending may suggest joint degeneration or inflammation. An exaggerated upper thoracic convex curvature could indicate poor posture or other spinal abnormalities but is not directly indicative of scoliosis.

4. Following a gunshot wound, an adult client has a hemoglobin level of 4 grams/dl (40 mmol/L SI). The nurse prepares to administer a unit of blood for an emergency transfusion. The client has AB negative blood type and the blood bank sends a unit of type A Rh negative, reporting that there is not type AB negative blood currently available. Which intervention should the nurse implement?

• A. Transfuse Type A negative blood until type AB negative is available.
• B. Recheck the client’s hemoglobin, blood type, and Rh factor.
• C. Administer normal saline solution until type AB negative is available.
• D. Obtain additional consent for the administration of type A negative blood.

Correct answer: A

Rationale: In emergency situations where AB negative blood is unavailable, type A negative blood can be transfused to a patient with AB negative blood type. Type A negative blood is compatible with AB negative blood, making it a suitable option until the correct blood type becomes available. Transfusion of Type A negative blood is crucial to address the severe anemia promptly. Rechecking the client’s hemoglobin, blood type, and Rh factor (Choice B) may delay necessary treatment. Administering normal saline solution (Choice C) is not a substitute for blood transfusion in cases of severe anemia. Obtaining additional consent for the administration of type A negative blood (Choice D) is unnecessary as the situation is emergent and the blood type is compatible.

5. The nurse assesses an older adult who is newly admitted to a long-term care facility. The client has dry, flaky skin and long thickened fingernails. The client has a medical history of a stroke which resulted in left-sided paralysis and dysphagia. In planning care for the client, which task should the nurse delegate to the unlicensed personnel (UAP)?

• A. Soak and file fingernails
• B. Offer fluids frequently
• C. Monitor skin elasticity
• D. Ambulate in the hallway

Correct answer: A

Rationale: Soaking and filing fingernails is a task that can be delegated to UAP. This task does not require specialized nursing skills and can be safely performed by unlicensed personnel. Offering fluids frequently, monitoring skin elasticity, and ambulating require more skilled assessments and interventions, which are responsibilities of the nurse. The client's dry, flaky skin and long thickened fingernails indicate the need for basic hygiene care, making it appropriate for delegation to unlicensed personnel.

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