Nursing Elites

1. A client who is 2 hours postpartum reports heavy bleeding and passing large clots. What is the nurse's priority action?

• A. Perform fundal massage
• B. Administer oxytocin IV
• C. Check vital signs
• D. Encourage the client to void

Correct answer: A

Rationale: The correct answer is A: Perform fundal massage. Fundal massage promotes uterine contractions, which is the initial action to reduce postpartum hemorrhage caused by uterine atony. Checking vital signs (choice C) is important but not the priority when active bleeding is present. Administering oxytocin IV (choice B) may be needed but is not the priority action. Encouraging the client to void (choice D) does not address the underlying issue of postpartum hemorrhage and should not be the priority.

2. A nurse is caring for a patient who has been in a motor vehicle crash and has a minor traumatic brain injury (TBI). What finding should the nurse recognize as a complication and report to the provider?

• A. Hypertension
• B. Vomiting
• C. Drainage from the ear
• D. Unequal pupils

Correct answer: D

Rationale: Unequal pupils are a sign of increased intracranial pressure or worsening brain injury, indicating a serious complication that requires immediate medical attention. Hypertension, vomiting, and drainage from the ear are not typically associated with minor traumatic brain injury complications; therefore, they are not the priority findings to report to the provider.

3. A nurse is assessing a 1-hour postpartum client and notes a boggy uterus located 2 cm above the umbilicus. Which of the following actions should the nurse take first?

• A. Take vital signs
• B. Assess lochia
• C. Massage the fundus
• D. Give oxytocin IV bolus

Correct answer: C

Rationale: When a nurse assesses a 1-hour postpartum client with a boggy uterus located 2 cm above the umbilicus, it indicates uterine atony. The first action the nurse should take is to massage the fundus. Fundal massage helps stimulate uterine contractions, which will reduce bleeding and prevent postpartum hemorrhage. Taking vital signs, assessing lochia, or administering an oxytocin IV bolus are important interventions but should come after addressing uterine atony through fundal massage.

4. A nurse is caring for a client who is 2 hours postpartum following a vaginal birth. The client reports heavy bleeding and passing large clots. What is the priority action for the nurse to take?

• A. Administer oxytocin IV
• B. Perform fundal massage
• C. Check vital signs
• D. Encourage the client to void

Correct answer: B

Rationale: Performing fundal massage is the priority action to take in this situation. Fundal massage helps stimulate uterine contractions, which can reduce postpartum bleeding. Uterine atony, the most common cause of early postpartum hemorrhage, can be addressed effectively through fundal massage. Administering oxytocin IV, although important, should come after initiating fundal massage. Checking vital signs is also crucial but not the immediate priority. Encouraging the client to void does not directly address the heavy bleeding and passing of large clots; hence, it is not the priority action.

5. A client who was incarcerated for theft is addressing the group in a County Jail health clinic. Which of the following is an example of reaction formation?

• A. I steal things because it’s the only way I can keep my mind off my bad marriage
• B. I can’t believe I was accused of something I didn’t do
• C. I don’t want to talk about my feelings right now; we will talk more next time
• D. I think that people should earn money honestly, even though I stole

Correct answer: D

Rationale: The correct answer is D because reaction formation occurs when a person expresses the opposite of what they feel. In this case, the client is advocating for honesty, despite their own history of theft. Choice A discusses stealing to distract from a bad marriage, which does not involve expressing the opposite of one's feelings. Choice B focuses on denial, not reaction formation. Choice C involves delaying emotional discussion, which is not related to expressing the opposite of one's true feelings.

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