Nursing Elites

1. During data collection of a client with suspected carpal tunnel syndrome, a nurse plans to perform the Phalen test. The nurse should ask the client to perform which activity?

• A. Dorsiflex the foot
• B. Plantarflex the foot
• C. Hold the hands back to back while flexing the wrists 90 degrees for 60 seconds
• D. Hyperextend the fingers with the palmar surfaces of the hands touching, holding the position for 60 seconds

Correct answer: C

Rationale: In the Phalen test, the nurse asks the client to hold the hands back to back while flexing the wrists 90 degrees. This position puts pressure on the median nerve, eliciting symptoms in carpal tunnel syndrome. Dorsiflexing or plantarflexing the foot and hyperextending the fingers are not associated with testing for carpal tunnel syndrome. Acute flexion of the wrist for 60 seconds produces no symptoms in the normal hand.

2. The teaching plan for a postpartum client who is about to be discharged should include which of the following instructions?

• A. "It is normal for your breasts to be tender. You should call the physician if you also have redness and fatigue."?
• B. "Because your baby was delivered vaginally, you might have to urinate more frequently."?
• C.
• D. "Be sure to call your physician if your vaginal discharge becomes bright red."?

Correct answer: D

Rationale:

3. A new mother is being discharged from the maternity unit and provided with information about signs and symptoms to report to her health care provider. Which statement by the mother indicates a need for further information?

• A. ''I will call my nurse-midwife if I experience any redness, swelling, or tenderness in my legs.''
• B. ''My temperature needs to remain within a normal range.''
• C. ''Frequent urination and burning when I urinate are expected.''
• D. ''Feelings of pelvic fullness or pelvic pressure are a sign of a problem.''

Correct answer: C

Rationale: The correct answer is 'Frequent urination and burning when I urinate are expected.' This statement by the mother indicates a need for further information because these symptoms are not normal and could indicate a urinary tract infection or another issue that needs medical attention. The other choices correctly reflect signs and symptoms that should be reported to the health care provider. Redness, swelling, or tenderness in the legs can indicate a blood clot, and feelings of pelvic fullness or pressure can be signs of a problem. Monitoring temperature is also important to ensure there is no infection or other complications postpartum.

4. The LPN is taking care of a client who is on Phenelzine (Nardil) for depression. Which meal would the nurse encourage the client to avoid?

• A. steak and potatoes
• B. prosciutto and cheese plate
• C. orange juice and toast
• D. carbonated water, shrimp and rice

Correct answer: B

Rationale: The correct answer is 'prosciutto and cheese plate.' Phenelzine (Nardil) is an MAOI (Monoamine Oxidase Inhibitor), and clients on these drugs should avoid foods high in tyramine due to the risk of dangerous elevations in blood pressure. Prosciutto and aged cheeses are examples of foods rich in tyramine, so they should be avoided. Choices A, C, and D do not contain high levels of tyramine and are considered safe to consume while on Phenelzine.

5. A nurse auscultating the fetal heart rate (FHR) of a pregnant client in the first trimester of pregnancy notes that the FHR is 160 beats/min. With this information, what should be the nurse's next action?

• A. Notify the healthcare provider of the finding.
• B. Document the findings.
• C. Tell the client that the FHR is faster than normal but that it is nothing to be concerned about at this time.
• D. Wait 15 minutes and then recheck the FHR.

Correct answer: B

Rationale: An FHR of 160 beats/min in the first trimester of pregnancy is within the normal range, which is generally 120 to 160 beats/min. The appropriate action for the nurse in this situation is to document the findings. There is no need to notify the healthcare provider as this is a normal finding. Informing the client that the FHR is faster than normal may cause unnecessary anxiety, as it falls within the expected range. Waiting to recheck the FHR is not necessary since the rate is already within the normal range.

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