Nursing Elites

1. A client is recovering from a craniotomy and has a ventriculostomy in place. The nurse notices the drainage from the ventriculostomy is suddenly increasing. What should the nurse do first?

• A. Increase the head of the bed to 45 degrees.
• B. Clamp the ventriculostomy tube.
• C. Notify the healthcare provider immediately.
• D. Measure the client's head circumference.

Correct answer: C

Rationale: A sudden increase in drainage from a ventriculostomy could indicate a serious complication such as increased intracranial pressure or hemorrhage. The priority action in this situation is to notify the healthcare provider immediately to ensure prompt evaluation and intervention. Increasing the head of the bed may be beneficial in some situations but is not the first action to take. Clamping the ventriculostomy tube is inappropriate as it can lead to increased intracranial pressure. Measuring the client's head circumference is not the priority when there is a sudden increase in ventriculostomy drainage.

2. Based on the principle of asepsis, which situation should the nurse consider to be sterile?

• A. A one-inch border around the edges of a sterile field set up in the operating room
• B. A sterile glove that the nurse thinks might have touched her hair
• C. A wrapped, unopened sterile 4x4 gauze pad placed on a damp tabletop
• D. An open sterile Foley catheter kit set up on a table at the nurse's waist level

Correct answer: D

Rationale: The correct answer is D because an open sterile Foley catheter kit set up at waist level is considered sterile if it has not been contaminated. Choice A is incorrect because the one-inch border around a sterile field is considered non-sterile. Choice B is incorrect because a sterile glove that might have touched the nurse's hair is likely contaminated. Choice C is incorrect because a wrapped, unopened sterile gauze pad placed on a damp tabletop may have become contaminated.

3. The nurse is performing a psychosocial assessment on an adolescent aged 14. Which emotional response is typical during early adolescence?

• A. Frequent anger
• B. Cooperativeness
• C. Moodiness
• D. Combativeness

Correct answer: C

Rationale: Moodiness is a typical emotional response during early adolescence. Hormonal changes and developmental challenges contribute to this behavior. While anger and combativeness can also be present during adolescence, they are not as consistently typical as moodiness. Cooperativeness, on the other hand, is a trait more commonly associated with later stages of development and maturity, rather than early adolescence.

4. A new mother who is breastfeeding her newborn for the first time after delivery reports nipple pain when the baby sucks. Based on this client problem, which action should the PN take?

• A. Ensure that all the areolar tissue of the nipple is in the infant's mouth
• B. Have the mother reposition the infant from the cradle to the football hold
• C. Check for engorgement and assess the nipples for cracks or lesions
• D. Apply a warm compress to the breast for 10 minutes before each feeding

Correct answer: A

Rationale: Proper latch, including all the areolar tissue in the infant's mouth, is essential to prevent nipple pain and ensure effective breastfeeding. Option A is correct because ensuring that all the areolar tissue of the nipple is in the infant's mouth helps achieve a good latch, reducing nipple pain. Option B is incorrect as repositioning the infant may not address the root cause of the pain related to latch issues. Option C is incorrect because while checking for engorgement and nipple issues is important, it does not directly address the latch concern causing the pain. Option D is incorrect as applying a warm compress is not recommended for breastfeeding mothers; a warm compress can help with pain associated with engorgement, but it does not address latch issues.

5. A client who had a thyroidectomy 24 hours ago reports tingling around the mouth and in the fingertips. What should the nurse do first?

• A. Check the client’s calcium levels.
• B. Administer a dose of calcium gluconate.
• C. Assess the client's incision site for bleeding.
• D. Notify the healthcare provider.

Correct answer: A

Rationale: Tingling around the mouth and in the fingertips can indicate hypocalcemia, a potential complication after thyroidectomy due to accidental damage to the parathyroid glands. Checking calcium levels is crucial as it helps in diagnosing hypocalcemia accurately. Administering calcium without knowing the actual calcium levels can be dangerous. Assessing the incision site for bleeding is important but not the priority in this situation. Notifying the healthcare provider can be done after assessing and managing the immediate concern of hypocalcemia.

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