Nursing Elites

1. A nurse is caring for a client who is 8 hours postpartum following a vaginal birth. The client reports passing large clots and heavy bleeding. Which of the following actions should the nurse take?

• A. Massage the fundus
• B. Administer methylergonovine
• C. Increase the IV fluid rate
• D. Notify the healthcare provider

Correct answer: A

Rationale: Heavy bleeding and the passage of large clots after childbirth can indicate uterine atony. The nurse should first attempt to massage the fundus to stimulate uterine contractions and control the bleeding. Massaging the fundus helps the uterus to contract and may help prevent further bleeding. Administering methylergonovine (Choice B) is not the initial intervention for uterine atony. Increasing the IV fluid rate (Choice C) may not address the underlying cause of the bleeding. Notifying the healthcare provider (Choice D) can be done after attempting initial interventions like fundal massage.

2. A nurse receives a report on four clients. Which client should the nurse assess first?

• A. A client scheduled for chemotherapy with a hemoglobin of 9 g/dL
• B. A client 24 hours post-TURP with small blood clots in the catheter
• C. A client receiving a blood transfusion who reports low back pain
• D. A client with a new colostomy and a reddish-pink stoma

Correct answer: C

Rationale: The correct answer is C. Low back pain during a blood transfusion is a classic sign of a transfusion reaction, specifically a transfusion-associated circulatory overload (TACO) or hemolytic reaction, both of which require immediate attention to prevent serious complications. Assessing this client first is crucial to ensure prompt intervention. Choices A, B, and D do not indicate immediate life-threatening complications and can be addressed after the client experiencing low back pain during a blood transfusion is stabilized.

3. A nurse is assessing a client who has anemia. Which of the following findings should the nurse expect?

• A. Bounding pulse
• B. Conjunctival pallor
• C. Elevated blood pressure
• D. Glossitis

Correct answer: B

Rationale: The correct answer is B: Conjunctival pallor. In anemia, there is a decrease in hemoglobin levels, leading to paleness of the conjunctiva. This is a common finding in individuals with anemia. Bounding pulse (choice A) is not typically associated with anemia but can be seen in conditions like hyperthyroidism. Elevated blood pressure (choice C) is not a common finding in anemia; instead, blood pressure may be low due to decreased oxygen-carrying capacity. Glossitis (choice D), or a swollen tongue, can be seen in certain types of anemia but is not as specific or common as conjunctival pallor.

4. A client receiving chemotherapy is experiencing neutropenia. Which of the following should the nurse include in this client's education?

• A. Track oral temperature weekly
• B. Gardening is a good form of mild exercise
• C. Avoid crowded events
• D. Eat plenty of fresh fruits and vegetables

Correct answer: C

Rationale: Clients with neutropenia have a weakened immune system, making them susceptible to infections. Avoiding crowded events helps reduce the risk of exposure to pathogens, thereby minimizing the chance of infections. Tracking oral temperature is important for detecting fever early, which is a sign of infection and requires immediate medical attention. While gardening can be a good form of exercise, clients with neutropenia should avoid it due to the risk of exposure to bacteria and fungi present in soil. Eating fresh fruits and vegetables is generally encouraged for overall health but may carry a risk of bacterial contamination, which could be harmful to a client with neutropenia.

5. A healthcare provider is assessing a client with congestive heart failure. Which of the following signs should the healthcare provider monitor?

• A. Peripheral edema
• B. Decreased appetite
• C. Fatigue
• D. All of the above

Correct answer: D

Rationale: Correct! In a client with congestive heart failure, peripheral edema, decreased appetite, and fatigue are important signs to monitor as they can indicate worsening heart failure. Peripheral edema is a common sign of fluid retention due to the heart's inability to pump effectively, decreased appetite may indicate worsening heart function, and fatigue can be a result of inadequate cardiac output. Monitoring all these signs is crucial for early intervention and management. Choices A, B, and C are incorrect because monitoring only one symptom may not provide a comprehensive assessment of the client's condition.

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