Nursing Elites

1. A nurse is performing a newborn assessment and notes a soft, swollen area on the newborn's scalp that does not cross the suture line. Which of the following should the nurse document?

• A. Cephalohematoma
• B. Caput succedaneum
• C. Subdural hematoma
• D. Molding

Correct answer: A

Rationale: The correct answer is A, cephalohematoma. A cephalohematoma is a collection of blood between the periosteum and the skull that does not cross the suture line. It is caused by trauma during birth and typically resolves on its own. Choice B, caput succedaneum, is characterized by diffuse edema over a newborn's scalp that crosses suture lines. Choice C, subdural hematoma, is a more serious condition involving bleeding between the dura mater and the brain. Choice D, molding, refers to the shaping of the fetal head during passage through the birth canal. Therefore, the nurse should document cephalohematoma in this scenario as it aligns with the description of a soft, swollen area on the newborn's scalp that does not cross the suture line.

2. A client with chronic kidney disease is about to start hemodialysis. Which of the following instructions should the nurse include?

• A. Increase protein intake between dialysis sessions
• B. Reduce potassium intake
• C. Avoid iron supplements
• D. Expect weight gain after each dialysis session

Correct answer: B

Rationale: The correct answer is to instruct the client to reduce potassium intake. Clients with chronic kidney disease should limit potassium intake to prevent hyperkalemia, as the kidneys may struggle to remove excess potassium. Increasing protein intake between dialysis sessions (Choice A) is not recommended as it can increase urea production, adding to the workload of the kidneys. Avoiding iron supplements (Choice C) is not necessary unless iron levels are high. Expecting weight gain after each dialysis session (Choice D) is incorrect as patients typically experience weight loss due to fluid removal during dialysis.

3. A client scheduled for an electroencephalogram (EEG) is receiving teaching from a nurse. Which statement by the client indicates an understanding of the teaching?

• A. “I should not wash my hair before the procedure.”
• B. “I will be given a sedative 1 hour before the procedure.”
• C. “I should refrain from eating before the procedure.”
• D. “I will be exposed to flashes of light during the procedure.”

Correct answer: D

Rationale: The correct answer is D. During an electroencephalogram (EEG), flashes of light or patterns are often used to stimulate the brain and provoke responses, helping to assess brain activity and the potential for seizures. Choices A, B, and C are incorrect because washing the hair, receiving a sedative, and refraining from eating are not usually related to EEG procedures and do not reflect understanding of the teaching provided by the nurse.

4. A client has been prescribed metformin. What should be included in the teaching?

• A. It can cause weight gain
• B. Take it with food
• C. It is an insulin
• D. Monitor for hyperglycemia

Correct answer: B

Rationale: The correct answer is to take metformin with food. This is important to minimize gastrointestinal side effects and improve absorption. Choice A is incorrect as metformin is not typically associated with weight gain. Choice C is wrong as metformin is not an insulin but a medication that helps control blood sugar levels. Choice D is also incorrect as metformin is not known to cause hyperglycemia.

5. A nurse is providing teaching for a client who has GERD. Which of the following assessment findings should the nurse expect to find?

• A. Shortness of breath
• B. Rebound tenderness
• C. Atypical chest pain
• D. Vomiting blood

Correct answer: C

Rationale: The correct answer is C: Atypical chest pain. GERD often presents with atypical chest pain due to acid reflux, which can mimic the symptoms of cardiac conditions but is related to the esophagus. Shortness of breath (choice A) is not a typical assessment finding in GERD. Rebound tenderness (choice B) is associated with peritoneal inflammation, not GERD. Vomiting blood (choice D) is a severe symptom that may indicate esophageal damage but is not a common assessment finding in GERD.

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