Nursing Elites

1. A client is in active labor and is receiving an epidural for pain relief. Which of the following should the nurse monitor as the priority?

• A. Fetal heart rate
• B. Client's blood pressure
• C. Client's respiratory rate
• D. Client's pain level

Correct answer: B

Rationale: The most common side effect of an epidural is hypotension, which can compromise placental perfusion. Monitoring the client's blood pressure is the priority to ensure maternal and fetal well-being. Fetal heart rate is important but monitoring the client's blood pressure takes precedence due to the risk of hypotension. Respiratory rate and pain level monitoring are also important but not the priority in this scenario.

2. While receiving a change of shift report on a group of clients, which patient should the nurse assess first?

• A. The client who has a fractured femur and reports sharp chest pain.
• B. The client who has a fever and is receiving antibiotics.
• C. The client who has a urinary tract infection and reports pain with urination.
• D. The client who is scheduled for surgery in the afternoon.

Correct answer: A

Rationale: The nurse should assess the client with a fractured femur and sharp chest pain first. Sharp chest pain in this client may indicate a pulmonary embolism, a life-threatening condition requiring immediate attention. The other options describe important patient conditions but do not pose an immediate threat to life like a potential pulmonary embolism does.

3. A healthcare professional is assessing a client for signs of hypoglycemia. Which of the following findings should the healthcare professional look for?

• A. Increased thirst
• B. Fatigue
• C. Weight gain
• D. Elevated blood pressure

Correct answer: B

Rationale: The correct answer is B: Fatigue. Fatigue, along with symptoms like shakiness and irritability, are common signs of hypoglycemia. Increased thirst (Choice A) is more indicative of hyperglycemia. Weight gain (Choice C) is not typically associated with hypoglycemia. Elevated blood pressure (Choice D) is not a common sign of hypoglycemia.

4. A nurse on a rehab unit is creating a plan of care for a newly admitted patient who has difficulty swallowing following a stroke. Which interprofessional team members should the nurse anticipate consulting?

• A. Physical therapist
• B. Speech-language pathologist
• C. Social worker
• D. Respiratory therapist

Correct answer: B

Rationale: The correct answer is B: Speech-language pathologist. A speech-language pathologist specializes in assessing and treating swallowing disorders, making them the most appropriate consultant for a patient with difficulty swallowing following a stroke. While other interprofessional team members such as a physical therapist (choice A), social worker (choice C), and respiratory therapist (choice D) may play important roles in the patient's care, the primary focus for swallowing difficulties would be the speech-language pathologist.

5. A client is to undergo a liver biopsy. Which of the following instructions should the nurse provide to the client following the procedure?

• A. “Lie on your left side.”
• B. “Lie on your right side.”
• C. “Increase your fluid intake.”
• D. “Decrease your fluid intake.”

Correct answer: B

Rationale: Following a liver biopsy, the nurse should instruct the client to lie on the right side to promote hemostasis. This position helps apply pressure to the biopsy site, reducing the risk of bleeding. Instructing the client to lie on the left side (Choice A) would not provide the same benefit. Increasing fluid intake (Choice C) is generally beneficial post-procedure to prevent dehydration and promote healing. Decreasing fluid intake (Choice D) is not advisable as it can lead to dehydration and potential complications.

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