Nursing Elites

1. A client who is at 36 weeks of gestation is scheduled for a nonstress test. Which of the following client statements indicates an understanding of the teaching?

• A. I should fast for 12 hours before the test.
• B. I should expect the test to take about 10 minutes.
• C. I should have a full bladder for this test.
• D. I will need to have my blood glucose checked before the test.

Correct answer: B

Rationale: The correct answer is B. The nonstress test takes about 10 minutes and evaluates fetal heart rate in response to fetal movement. Choice A is incorrect because fasting is not required for a nonstress test. Choice C is incorrect as a full bladder is not necessary for this test. Choice D is incorrect as blood glucose checking is not typically part of a nonstress test.

2. A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take?

• A. Insert the catheter 7.5 cm (3 in) into the urethra.
• B. Insert the catheter until urine flow is established.
• C. Cleanse the catheter with sterile water before insertion.
• D. Insert the catheter 5 cm (2 in) into the urethra.

Correct answer: B

Rationale: The correct action for the nurse is to insert the catheter until urine flow is established. This helps ensure proper placement and reduces the risk of trauma. Choice A (7.5 cm) and Choice D (5 cm) provide specific measurements that may not be appropriate for all individuals as catheter insertion depth can vary. Choice C is incorrect as catheters should be cleansed with an appropriate solution such as sterile saline, not sterile water.

3. A nurse is planning care for a client who is 6 hours postoperative following a total hip arthroplasty. Which of the following interventions should the nurse include in the plan of care?

• A. Place a wedge under the client's affected leg.
• B. Keep the client's hip flexed at a 90° angle.
• C. Position the client with the legs extended and the hip externally rotated.
• D. Keep the client's leg abductor pillow in place while in bed.

Correct answer: D

Rationale: In caring for a client 6 hours postoperative following a total hip arthroplasty, it is crucial to keep the leg abductor pillow in place while in bed. This intervention helps prevent hip dislocation by maintaining proper alignment and stability of the hip joint. Placing a wedge under the client's affected leg (Choice A) may not provide adequate support and could potentially compromise the surgical site. Keeping the client's hip flexed at a 90° angle (Choice B) or positioning the client with the legs extended and the hip externally rotated (Choice C) are not recommended post total hip arthroplasty as they may increase the risk of hip dislocation.

4. A nurse in a pediatric clinic is reviewing laboratory findings for a school-age child. Which of the following findings should the nurse report to the provider?

• A. Hgb 12.5 g/dL
• B. Platelets 250,000/mm3
• C. WBC 14,000/mm3
• D. Hct 40%

Correct answer: D

Rationale: The correct answer is D: 'Hct 40%'. An abnormal hematocrit (Hct) level can indicate various conditions such as dehydration, overhydration, or blood disorders, and requires immediate attention from the healthcare provider. Choices A, B, and C are within normal ranges and do not typically warrant immediate provider notification. Hgb 12.5 g/dL (Choice A) is a normal hemoglobin level, Platelets 250,000/mm3 (Choice B) is a normal platelet count, and WBC 14,000/mm3 (Choice C) is slightly elevated but not significantly high to require urgent reporting.

5. A nurse is caring for a client who has a prescription for a high-protein diet to promote wound healing. Which of the following foods should the nurse recommend?

• A. Bananas
• B. Fish
• C. White bread
• D. Chicken breast

Correct answer: D

Rationale: Corrected Rationale: Chicken breast is an excellent source of protein, which is essential for wound healing due to its role in tissue repair and regeneration. Fish is also a good source of protein, but chicken breast is a more commonly recommended option for wound healing due to its high protein content and lower fat content compared to some types of fish. Bananas and white bread, on the other hand, are not high-protein foods and do not provide the necessary nutrients for wound healing.

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