Nursing Elites

1. A nurse auscultating the fetal heart rate (FHR) of a pregnant client in the first trimester of pregnancy notes that the FHR is 160 beats/min. With this information, what should be the nurse's next action?

• A. Notify the healthcare provider of the finding.
• B. Document the findings.
• C. Tell the client that the FHR is faster than normal but that it is nothing to be concerned about at this time.
• D. Wait 15 minutes and then recheck the FHR.

Correct answer: B

Rationale: An FHR of 160 beats/min in the first trimester of pregnancy is within the normal range, which is generally 120 to 160 beats/min. The appropriate action for the nurse in this situation is to document the findings. There is no need to notify the healthcare provider as this is a normal finding. Informing the client that the FHR is faster than normal may cause unnecessary anxiety, as it falls within the expected range. Waiting to recheck the FHR is not necessary since the rate is already within the normal range.

2. A client who is immobilized secondary to traction is complaining of constipation. Which of the following medications should the nurse expect to be ordered?

• A. Advil
• B. Anasaid
• C. Clinocil
• D. Colace

Correct answer: D

Rationale: The correct answer is Colace. Colace is a stool softener that helps relieve constipation by drawing more water into the bowel, making the stool softer and easier to pass. This is beneficial for an immobilized client as it can help prevent constipation due to decreased mobility. Options A, B, and C (Advil, Anasaid, Clinocil) are not indicated for constipation relief. Advil and Anasaid are nonsteroidal anti-inflammatory drugs used for pain relief, while Clinocil is a fictional medication.

3. Which of the following substances need to be assessed when completing a family health assessment?

• A. coffee, tea, cola, cocoa, and other substances
• B. alcohol, tobacco, and illegal substances
• C. medicines prescribed by a physician
• D. all of the above

Correct answer: D

Rationale: When completing a family health assessment, it is essential to assess all substances consumed by family members, including coffee, tea, cola, cocoa, alcohol, tobacco, illegal substances, and medicines prescribed by a physician. Understanding the complete picture of substance use within the family is crucial for identifying potential health risks and providing appropriate care. Choice D, 'all of the above,' is the correct answer as it encompasses the comprehensive assessment of all substances. Choices A, B, and C are incorrect as they only present partial aspects of substance assessment and do not cover the full range of substances that should be evaluated in a family health assessment.

4. The nurse is observing a client self-administer two crushable medications through their G-tube. Which of the following would indicate a need for further instruction?

• A. The client flushes the G-tube before administering the medications, in between the two medications, and after the medications.
• B. The client states they will remain in the Semi-Fowler's position for 30 minutes following the administration of the medications.
• C. The client mixes each medication separately in warm water.
• D. The client mixes their medications with their tube-feeding formula.

Correct answer: D

Rationale: The correct answer is that the client mixes their medications with their tube-feeding formula. Medications should not be mixed with tube-feeding formula or other medications as it may alter their effectiveness. The G-tube should be flushed before, between, and after the medications to prevent clogging and ensure proper administration. The client should remain in the Semi-Fowler's position for at least 30 minutes after medication administration to prevent reflux. Choice B is correct as it aligns with the proper post-administration positioning. Choices A and C are incorrect as flushing the G-tube before, between, and after medications, and mixing each medication separately in warm water are appropriate procedures that do not indicate a need for further instruction.

5. The nurse is caring for a postpartum woman who has relinquished her baby for adoption. The care plan for the client should include which of the following priority strategies?

• A. Make a referral for grief counseling.
• B. Allow the woman to see her baby initially and respect her wishes for further visits.
• C. Provide opportunities for the woman to express her feelings.
• D. Inform the woman she has the right to change her mind about relinquishment.

Correct answer: C

Rationale: When caring for a postpartum woman who has relinquished her baby for adoption, it is crucial for the nurse to provide opportunities for the woman to express her feelings. Most women who make this decision have done so with love and pain, and it is essential to allow them to verbalize their emotions, which may include grief, loneliness, and guilt. Referring the woman for grief counseling may be necessary if she lacks a support system or requests help to navigate her grief. Allowing the woman to see her baby is important, and the nurse should respect her wishes regarding visitation as it can aid in the grief process. While the woman does have the right to change her mind about relinquishment until final legal arrangements are made, suggesting this option may inadvertently influence her decision and should be approached cautiously. Therefore, providing emotional support and opportunities for expression are the priority strategies in this situation.

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