Nursing Elites

1. At 42-weeks gestation, a client refuses induction and desires a natural delivery. What is the most important action for the nurse to take?

• A. Discuss alternative ways to support her birth plan.
• B. Explain the indications for induction in post-term pregnancy.
• C. Discuss the differences between labor with oxytocin and natural labor.
• D. Ask the healthcare provider to discuss the issue with the client.

Correct answer: A

Rationale: The correct answer is to discuss alternative ways to support her birth plan. It is crucial to respect the client's autonomy and desires while ensuring their safety and well-being. Choice B is incorrect because while educating the client about the indications for induction is important, it is not the most immediate action to take in this scenario. Choice C is incorrect as it focuses on comparing labor types rather than supporting the client's birth plan. Choice D is incorrect as the nurse should first engage with the client directly before involving the healthcare provider.

2. A 4-year-old child falls off a tricycle and is admitted for observation. How can the nurse best facilitate the child's cooperation during the assessment?

• A. Ask the parent to hold the child during the assessment.
• B. Allow the child to play with a syringe without a needle.
• C. Ask the child to blow out the penlight as if to simulate success.
• D. Explain the function of each organ during the assessment.

Correct answer: C

Rationale: Engaging the child in blowing out the penlight simulates play and can reduce fear, helping with cooperation during the assessment. Choice A is not recommended as it may increase anxiety by separating the child from the parent. Choice B is not appropriate as it involves playing with a syringe, which may not be safe or suitable. Choice D is not ideal for a 4-year-old child as understanding organ functions may be beyond their developmental level.

3. The mother of a 2-day-old infant girl expresses concern about a 'flea bite' type rash on her daughter's body. The nurse identifies a pink papular rash with vesicles superimposed over the thorax, back, buttocks, and abdomen. Which explanation should the nurse offer?

• A. We need to monitor the rash for signs of worsening or fever
• B. Your baby may have an allergic reaction to laundry detergent
• C. This is a common newborn rash that will resolve after several days
• D. This is likely a bacterial infection requiring antibiotics

Correct answer: C

Rationale: The rash described is typical of erythema toxicum neonatorum, a common and benign newborn rash that resolves on its own within a few days. No treatment is necessary, and the nurse should reassure the mother. Choice A is incorrect as the rash is self-limiting and does not require monitoring for worsening signs or fever. Choice B is incorrect as erythema toxicum neonatorum is not caused by an allergic reaction to laundry detergent. Choice D is incorrect as this rash is not indicative of a bacterial infection that requires antibiotics.

4. A client with acute kidney injury has an elevated creatinine level. What is the nurse's priority intervention?

• A. Administer diuretics as prescribed.
• B. Prepare the client for dialysis.
• C. Restrict the client’s fluid intake.
• D. Notify the healthcare provider immediately.

Correct answer: B

Rationale: The correct answer is B: Prepare the client for dialysis. Clients with acute kidney injury and elevated creatinine may require dialysis to support kidney function and remove waste products from the blood. Preparing for dialysis ensures timely intervention in preventing further complications. Administering diuretics (Choice A) may worsen the client's condition by further compromising kidney function. Restricting fluid intake (Choice C) may be necessary in some cases, but it is not the priority over preparing for dialysis. Notifying the healthcare provider (Choice D) is important, but the immediate priority is to prepare for dialysis to address the acute kidney injury and elevated creatinine level.

5. The nurse is caring for a client with a traumatic brain injury who is receiving mechanical ventilation. Which assessment finding indicates that the client may be experiencing increased intracranial pressure (ICP)?

• A. Client becomes increasingly lethargic
• B. Client's respiratory rate is 16 breaths per minute
• C. Client responds to verbal stimuli
• D. Client's pupils are equal and reactive

Correct answer: A

Rationale: Increased lethargy is a sign of worsening intracranial pressure, which can be life-threatening in clients with brain injuries. As ICP rises, it can lead to decreased level of consciousness, such as lethargy or even coma. Choices B, C, and D are not indicative of increased ICP. A normal respiratory rate, response to verbal stimuli, and equal reactive pupils do not specifically point towards increased intracranial pressure.

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