Nursing Elites

1. The teaching plan for a postpartum client who is about to be discharged should include which of the following instructions?

• A. "It is normal for your breasts to be tender. You should call the physician if you also have redness and fatigue."?
• B. "Because your baby was delivered vaginally, you might have to urinate more frequently."?
• C. "It is normal to run a low-grade temperature for a few days. If it is higher than 100�F, call your physician."?
• D. "Be sure to call your physician if your vaginal discharge becomes bright red."?

Correct answer: D

Rationale: The correct answer is to instruct the postpartum client to call the physician if their vaginal discharge becomes bright red. The vaginal discharge after birth is called lochia, and a return to red or containing clots could indicate impending hemorrhage or infection, necessitating notification of the physician. Choice A is incorrect because although some tenderness may be expected, redness and fatigue are clinical manifestations of mastitis, not normal postpartum changes. Choice B is also incorrect as increased frequency of urination after vaginal delivery could indicate a urinary tract infection, not a normal postpartum change. Choice C is incorrect because running a low-grade temperature for a few days is not expected postpartum; an elevated temperature above 100�F should be reported to the physician as it could indicate infection.

2. What is the threshold of dextrose concentrations that can safely be administered through a peripheral IV?

• A. Dextrose concentrations below 20% can be safely administered through a peripheral IV; dextrose concentrations above 20% should not be administered through a peripheral IV.
• B. Dextrose concentrations below 5% can be safely administered through a peripheral IV; dextrose concentrations above 5% should not be administered through a peripheral IV.
• C. Dextrose concentrations below 10% can be safely administered through a peripheral IV; dextrose concentrations above 10% should not be administered through a peripheral IV.
• D. Dextrose concentrations above 5% can be safely administered through a peripheral IV; dextrose concentrations below 5% should not be administered through a peripheral IV.

Correct answer: C

Rationale: Dextrose concentrations below 10% are considered safe for administration through a peripheral IV, as concentrations above this threshold can lead to phlebitis, causing inflammation of the vein. Concentrations above 10% should not be administered through a peripheral IV to prevent vein irritation. Choice A is incorrect because concentrations above 20% are too high for a peripheral IV. Choice B is incorrect as dextrose concentrations below 5% are too low to be effective. Choice D is incorrect because the statement is reversed, suggesting that concentrations above 5% are safe, which is not true.

3. A nurse is reviewing the findings of a physical examination documented in a client's record. Which piece of information does the nurse recognize as objective data?

• A. The client is allergic to strawberries
• B. The last menstrual period was 30 days ago
• C. The client takes acetaminophen (Tylenol) for headaches
• D. A 1-2-inch scar is present on the lower right portion of the abdomen

Correct answer: D

Rationale: Objective data in a physical examination are findings that the healthcare provider observes or measures directly. In this case, a 1 � 2-inch scar present on the lower right portion of the abdomen is a physical observation. Subjective data are based on what the client reports, such as allergies (Choice A), the date of the last menstrual period (Choice B), and self-reported medication use for headaches (Choice C). While these pieces of information are important for assessing the client's health, they are considered subjective data because they rely on the client's self-report rather than direct observation by the healthcare provider.

4. A nurse is preparing to auscultate for the presence of bowel sounds in a client who has just undergone surgery. The nurse places the stethoscope in which abdominal quadrant first?

• A. Left upper quadrant
• B. Left lower quadrant
• C. Right upper quadrant
• D. Right lower quadrant

Correct answer: D

Rationale: The correct answer is the right lower quadrant. The nurse starts auscultating in this quadrant at the ileocecal valve as bowel sounds are normally always present there. Then, the nurse proceeds to listen for bowel sounds in the other quadrants. Choices A, B, and C are incorrect as the initial placement of the stethoscope should be in the right lower quadrant to assess bowel sounds post-surgery.

5. A 35-year-old Latin-American client wishes to lose weight to reduce her chances of developing heart disease and diabetes. The client states, "I do not know how to make my diet work with the kind of foods that my family eats."? What should the nurse do first to help the client determine a suitable diet for disease prevention?

• A. Provide her with copies of the approved dietary guidelines from the American Diabetes Association and the American Heart Association.
• B. Ask the client to provide a list of the types of foods she eats to determine how to best meet her needs.
• C. Provide a high-protein diet plan for the client.
• D. Provide the client with information related to risk factors for heart disease and diabetes.

Correct answer: B

Rationale: The correct first step is to assess the client's current diet by asking her to provide a list of the types of foods she eats. This assessment will help the nurse determine a personalized dietary plan based on the guidelines from the American Diabetes Association and the American Heart Association. Providing the client with copies of the guidelines is important but not the initial action. A high-protein diet plan may not be suitable for all clients aiming to prevent heart disease and diabetes. While providing information on risk factors is important, it is not the primary step in assisting the client with determining a suitable diet for disease prevention.

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