Nursing Elites

1. A nurse is using Naegele’s rule to calculate the expected delivery date for a client whose last menstrual period was in October. What is the expected date?

• A. 711
• B. 1011
• C. 411
• D. 1211

Correct answer: A

Rationale: Using Naegele’s rule, to calculate the expected delivery date, you add one year, subtract three months, and add seven days to the first day of the last menstrual period. If the last menstrual period was in October, adding one year gives October of the following year. Subtracting three months gives July, and adding seven days gives the expected delivery date of July 11th. Therefore, the correct answer is 711. Choice B (1011) is incorrect as it doesn't follow Naegele’s rule calculations. Choices C (411) and D (1211) are also incorrect as they do not align with the correct application of Naegele’s rule.

2. In the nursing process, the evaluation phase is used to determine:

• A. Value of the nursing intervention
• B. Accuracy of problem identification
• C. Quality of the plan of care
• D. Degree of outcome achievement

Correct answer: D

Rationale: The evaluation phase of the nursing process is used to determine the degree of outcome achievement. It assesses whether the goals and outcomes set during the planning phase were met. Choice A is incorrect because it focuses on the worth of the intervention rather than the achievement of outcomes. Choice B is incorrect as it pertains to the assessment phase where problems are identified. Choice C is incorrect as it refers to the planning phase where the care plan is developed, not evaluated.

3. A nurse is assessing a newborn and notes that the infant has yellow-tinged skin. Which of the following is the priority nursing action?

• A. Assess the infant's bilirubin levels
• B. Initiate phototherapy
• C. Monitor the infant's temperature
• D. Encourage breastfeeding

Correct answer: A

Rationale: Yellow-tinged skin (jaundice) in a newborn can indicate hyperbilirubinemia. The priority action is to assess the infant's bilirubin levels to determine the severity of the jaundice and the need for further interventions, such as phototherapy. Initiating phototherapy (choice B) is premature without knowing the actual bilirubin levels. Monitoring the infant's temperature (choice C) is important but not the priority in this situation. Encouraging breastfeeding (choice D) is beneficial but not the priority when dealing with jaundice in a newborn.

4. A nurse is assessing a client 2 hours after a vaginal delivery and notes that the client's uterus is boggy and displaced to the right. Which of the following interventions should the nurse perform first?

• A. Assist the client to void
• B. Massage the uterus
• C. Administer oxytocin
• D. Encourage breastfeeding

Correct answer: A

Rationale: A boggy and displaced uterus is often a sign of bladder distention, which can prevent the uterus from contracting effectively. The priority intervention is to assist the client to void. By emptying the bladder, the uterus can return to midline and become firm. Massaging the uterus or administering oxytocin may be necessary but should come after addressing the bladder distention. Encouraging breastfeeding is important for uterine contraction but is not the priority in this situation.

5. A nurse is assessing a client who reports a possible exposure to HIV. Which of the following findings should the nurse identify as an early manifestation of HIV infection?

• A. Stomatitis
• B. Fatigue
• C. Wasting syndrome
• D. Lipodystrophy

Correct answer: B

Rationale: The correct answer is B: Fatigue. A client with early HIV infection can be asymptomatic or experience symptoms like viral infections, such as fever, rash, and fatigue. Fatigue is a common early manifestation of HIV infection due to the body's immune response. Stomatitis (choice A) is more commonly associated with oral health issues or infections. Wasting syndrome (choice C) and lipodystrophy (choice D) are more advanced manifestations seen in later stages of HIV infection, characterized by severe weight loss and changes in body fat distribution, respectively.

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