Nursing Elites

1. A nurse is teaching a prenatal class about infection prevention. Which of the following statements indicates an understanding of the teaching?

• A. I can visit someone with chickenpox 5 days after the sores crust.
• B. I should avoid cleaning my cat's litter box during pregnancy.
• C. I should wash my hands with hot water for 10 seconds after gardening.
• D. I can take antibiotics for viral infections.

Correct answer: B

Rationale: The correct answer is B because avoiding cleaning the cat's litter box during pregnancy reduces the risk of toxoplasmosis, which can be harmful to the developing fetus. Choice A is incorrect because visiting someone with chickenpox should be avoided as it is highly contagious. Choice C is incorrect as handwashing after gardening should involve soap and water, not just hot water, for effective infection prevention. Choice D is incorrect because antibiotics are ineffective against viral infections.

2. A nurse is planning care for a client who has unilateral paralysis and dysphagia following a right hemispheric stroke. Which of the following interventions should the nurse include in the plan?

• A. Place food on the left side of the client's mouth when they are ready to eat
• B. Provide assistance with the client's ADLs
• C. Maintain the client in an upright position
• D. Place the client's left arm on a pillow while they are sitting

Correct answer: D

Rationale: Placing the client's left arm on a pillow while they are sitting helps prevent shoulder displacement and provides support for the limb post-stroke. This positioning is important to maintain proper alignment and prevent complications. Choices A, B, and C are incorrect because placing food on the left side of the mouth, providing total assistance with ADLs, and maintaining the client on bed rest do not directly address the specific needs related to unilateral paralysis and dysphagia post right hemispheric stroke.

3. A nurse is assessing a client who has pericarditis. Which of the following findings is the priority?

• A. Paradoxical pulse
• B. Dependent edema
• C. Pericardial friction rub
• D. Substernal chest pain

Correct answer: A

Rationale: In a client with pericarditis, the priority finding is a paradoxical pulse. This is a crucial sign of cardiac tamponade, a life-threatening complication of pericarditis where fluid accumulates in the pericardial sac, causing compression of the heart. A paradoxical pulse is an exaggerated decrease in systolic blood pressure (>10 mmHg) during inspiration. Prompt recognition and intervention are essential to prevent hemodynamic instability and cardiac arrest. Dependent edema (choice B) is not typically associated with pericarditis. Pericardial friction rub (choice C) is a common finding in pericarditis but does not indicate the urgency of intervention as a paradoxical pulse. Substernal chest pain (choice D) is a classic symptom of pericarditis but is not as critical as a paradoxical pulse in the context of assessing for complications.

4. A nurse is planning care for a client who is 1 day postoperative following a hypophysectomy for the removal of a pituitary tumor. Which of the following findings requires further assessment by the nurse?

• A. Glasgow Coma Scale score of 15
• B. Blood drainage on the initial dressing measuring 3 cm
• C. Report of dry mouth
• D. Urinary output greater than fluid intake

Correct answer: D

Rationale: The correct answer is D. Urinary output greater than fluid intake could indicate diabetes insipidus, a complication following hypophysectomy. Diabetes insipidus is characterized by excessive urination and extreme thirst due to inadequate levels of antidiuretic hormone (ADH). Options A, B, and C are all expected findings in the immediate postoperative period following a hypophysectomy. A Glasgow Coma Scale score of 15 indicates the highest level of consciousness, blood drainage on the initial dressing is a common finding after surgery, and dry mouth can be a side effect of anesthesia and surgical procedures.

5. A nurse is caring for a client who has a chest tube following thoracic surgery. Which of the following actions should the nurse take?

• A. Clamp the chest tube when assisting the client out of bed.
• B. Empty the drainage system every 8 hours.
• C. Keep the collection device below the client's chest.
• D. Strip the chest tube every 4 hours.

Correct answer: C

Rationale: The correct action for the nurse to take is to keep the collection device below the client's chest. This positioning ensures proper drainage of fluid from the chest, preventing backflow of fluids. Clamping the chest tube when assisting the client out of bed is incorrect as it can lead to fluid accumulation and potential complications. Emptying the drainage system every 8 hours is necessary but not the priority over maintaining proper positioning. Stripping the chest tube every 4 hours is an outdated practice and can cause damage to the tissue and should be avoided.

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