Nursing Elites

1. A pregnant client is being educated by a nurse on nutrition and foods rich in folic acid. Which food item does the nurse inform the client contains the highest amount of folic acid?

• A. Pinto beans
• B. Lettuce
• C. Oranges
• D. Broccoli

Correct answer: A

Rationale: Pinto beans contain the highest amount of folic acid among the options provided, with 294 mcg per 1-cup serving. Oranges contain 44 mcg per 1-cup serving, lettuce contains 60 mcg per 1-cup serving, and broccoli contains 78 mcg per 1-cup serving. Therefore, pinto beans are the best choice for increasing folic acid intake during pregnancy. Choosing oranges, lettuce, or broccoli would not provide as much folic acid compared to pinto beans, making them less optimal choices for meeting folic acid requirements during pregnancy.

2. A nurse is preparing to auscultate a fetal heart rate (FHR). The nurse performs the Leopold maneuvers to determine the position of the fetus and then places the fetoscope over which part of the fetus?

• A. Back of the fetus
• B. Carotid artery in the neck of the fetus
• C. Brachial area of one extremity of the fetus
• D. Chest of the fetus

Correct answer: A

Rationale: The nurse would use the Leopold maneuvers to identify the position of the fetus and determine the location of the fetal back. The fetal heart rate (FHR) is most easily heard through the fetal back because it usually lies closest to the surface of the maternal abdomen. Auscultation of the FHR over the chest, carotid artery, or brachial area is not possible due to the fetal position within the maternal abdomen. Placing the fetoscope over the carotid artery or brachial area would not yield the fetal heart rate, and the chest area is not typically used for auscultating the FHR.

3. An older client reports that she has been awakening during the night, awakes early in the morning and is unable to fall back to sleep, and feels sleepy during the daytime. Based on these reported data, what should the nurse do?

• A. Encourage the client to consume stimulants such as caffeinated coffee or tea during the daytime hours.
• B. Ask the registered nurse to obtain a prescription for a nighttime sedative.
• C. Report the findings to the registered nurse.
• D. Document the findings in the medical record.

Correct answer: D

Rationale: Age-related changes in sleep include reduced sleep efficiency, increased incidence of nocturnal awakening, increased incidence of early-morning awakening, and increased daytime sleepiness. Since the reported data are normal age-related changes, the appropriate action for the nurse would be to document the findings in the medical record. Reporting the findings to the registered nurse is unnecessary as these changes are expected with aging and do not indicate a need for immediate intervention. Prescribing sedatives should be avoided as a first-line approach due to potential side effects and risks, especially in older adults. Encouraging the consumption of stimulants like caffeinated beverages during the daytime may further disrupt sleep patterns, which is counterproductive in addressing the client's reported sleep issues.

4. A woman who delivered a healthy newborn 6 hours earlier complains of discomfort at the episiotomy site. Which action by the nurse is the most appropriate?

• A. Administering an intravenous (IV) opioid analgesic
• B. Assisting the woman in taking a warm sitz bath
• C. Applying an ice pack to the perineum
• D. Contacting the registered nurse

Correct answer: C

Rationale: Applying an ice pack to the perineum is the most appropriate action in this scenario. Ice causes vasoconstriction, providing relief by numbing the area and preventing edema. It is typically used within the first 12 to 24 hours after birth. Assisting the woman in taking a warm sitz bath is more suitable after 24 hours as warm water can be soothing. Administering an IV opioid analgesic is excessive; an anesthetic spray is more appropriate for surface discomfort. Contacting the registered nurse is unnecessary as applying an ice pack is within the nurse's scope and can effectively address the discomfort without escalation.

5. Which of the following are included in the Rights of Medication Administration? Select all that apply.

• A. Right dose, right time, right explanation, right client, right route
• B. Right dose, right time, right client, right route
• C. Right dose, right time, right client
• D. Right time, right explanation, right client

Correct answer: B

Rationale: The Rights of Medication Administration include the right client, right drug, right dose, right route, and right time. An additional right that is sometimes included is the right documentation. The correct answer includes the essential rights that must be ensured during medication administration. Choice A is incorrect as 'right explanation' is not part of the traditional Rights of Medication Administration. Choice B is incorrect as 'right explanation' is not included, and choice C is missing the right route. Choice D is incorrect as it lacks the right dose and right route.

Similar Questions