Nursing Elites

1. A grand multiparous client had a precipitous delivery in the emergency room 6 hours ago. The client was given oxytocin intramuscularly after birth. The nurse examines the client and observes the pad under her buttocks is full of blood. Which action should the nurse take first?

• A. Place a new pad and weigh the pad removed to determine blood loss.
• B. Massage the fundus and express clots.
• C. Start an IV and begin an oxytocin infusion.
• D. Clean the perineal area and encourage her to breastfeed.

Correct answer: B

Rationale: Massaging the fundus and expressing clots helps contract the uterus and reduce postpartum hemorrhage.

2. What is the function of the cervix in reproduction?

• A. Accepts and interprets signals of sexual stimuli
• B. Secretes mucus to facilitate sperm transport
• C. Serves as the site for union of ovum and sperm
• D. Receives the penis during intercourse

Correct answer: B

Rationale: The cervix functions in reproduction by secreting mucus that facilitates the transport of sperm to the uterus. Choice A is incorrect because the cervix does not interpret signals of sexual stimuli. Choice C is incorrect as the site for the union of ovum and sperm is the fallopian tube. Choice D is incorrect as the cervix is not involved in receiving the penis during intercourse.

3. When taking blood pressure at the brachial artery, the nurse should place the client's arm in which position?

• A. Slightly above the level of the heart
• B. At the level of the heart
• C. At a level of comfort for the client
• D. Below the level of the heart

Correct answer: B

Rationale: When taking blood pressure at the brachial artery, it is crucial to place the client's arm at the level of the heart to ensure accurate measurement. Placing the arm above or below the heart level can lead to incorrect readings. Option A, placing the arm slightly above the heart level, would result in falsely lower blood pressure readings as gravity would assist in a lower value. Option C, placing the arm at a level of comfort for the client, may not align with the standardized technique required for accurate blood pressure assessment. Option D, placing the arm below the level of the heart, would likely yield falsely higher blood pressure readings due to increased hydrostatic pressure pushing the blood against gravity.

4. When preparing to administer blood to a client, what is the most important action to ensure client safety during this procedure?

• A. Check the client’s blood type compatibility
• B. Monitor the client for signs of transfusion reaction
• C. Verify the correct client and blood product with another healthcare professional
• D. All of the above

Correct answer: D

Rationale: The most important action to ensure client safety during a blood transfusion is to implement multiple safety checks. Checking the client’s blood type compatibility is crucial as it helps prevent major transfusion reactions. Monitoring the client for signs of transfusion reaction is essential to detect any adverse reactions early. Verifying the correct client and blood product with another healthcare professional adds an extra layer of safety by ensuring the right blood is administered to the right patient. Choosing 'All of the above' (Option D) is the correct answer because each action plays a vital role in ensuring the safety and well-being of the client during a blood transfusion. Options A, B, and C are not exclusive; they complement each other to provide comprehensive safety measures.

5. A client is being treated for dehydration. Which clinical finding would indicate that treatment is effective?

• A. Dry mucous membranes
• B. Increased urine output
• C. Tachycardia
• D. Hypotension

Correct answer: B

Rationale: The correct answer is B: Increased urine output. When a client is being treated for dehydration, increased urine output is a positive indication that the treatment is effective. This signifies that the body is beginning to rehydrate and eliminate excess fluid. Choices A, C, and D are incorrect because dry mucous membranes, tachycardia, and hypotension are all associated with dehydration and would not be signs of effective treatment.

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