Nursing Elites

1. A client who is at 38 weeks gestation, is in active labor, and has ruptured membranes is being cared for by a nurse. What action should the nurse take?

• A. Insert an indwelling urinary catheter
• B. Apply fetal heart rate monitor
• C. Initiate fundal massage
• D. Initiate an oxytocin IV infusion

Correct answer: B

Rationale: When caring for a client in active labor with ruptured membranes, the priority action for the nurse is to apply a fetal heart rate monitor. This helps monitor the well-being of the fetus during labor and delivery, enabling timely interventions if any fetal distress is detected. Inserting an indwelling urinary catheter may be required in some cases, but it is not the priority in the given scenario. Fundal massage is typically done after delivery to help the uterus contract and prevent postpartum hemorrhage. Initiating an oxytocin IV infusion may be indicated to augment labor, but it is not the initial action needed in this situation.

2. A client with vision loss is under the care of a nurse. Which of the following actions should the nurse AVOID?

• A. Keep objects in the client's room in the same place
• B. Ensure there is high-wattage lighting in the client's room
• C. Approach the client from the side
• D. Allow extra time for the client to perform tasks

Correct answer: C

Rationale: Approaching a client with vision loss from the side can startle them and may lead to accidents or discomfort. It is important to approach them from the front so they are aware of your presence. Keeping objects in the same place aids in familiarity and reduces the risk of falls. High-wattage lighting enhances visibility for the client. Allowing extra time for tasks accommodates the client's potential slower pace and ensures they can perform tasks safely.

3. During a seizure, what is the primary intervention?

• A. Protect the patient from injury
• B. Insert an airway
• C. Elevate the head of the bed
• D. Withdraw all pain medications

Correct answer: A

Rationale: The primary intervention during a seizure is to protect the patient from injury. This involves creating a safe environment by moving harmful objects away, cushioning the head, and staying with the patient until the seizure ends. Inserting an airway is only necessary if the patient's airway is obstructed, not routinely during a seizure. Elevating the head of the bed is not a priority during an active seizure as it won't affect the seizure's outcome. Withdrawing all pain medications is not a standard practice unless there are specific contraindications related to the seizure itself.

4. A group of clients are being educated about influenza. Which of the following client statements indicates an understanding of the teaching?

• A. ''I should wash my hands after blowing my nose to prevent spreading the virus.''
• B. ''I need to avoid drinking fluids if I develop symptoms.''
• C. ''I need a flu shot every 2 years because of the different flu strains.''
• D. ''I should cover my mouth with my hand when I sneeze.''

Correct answer: A

Rationale: The correct answer is, 'I should wash my hands after blowing my nose to prevent spreading the virus.' This statement shows understanding of the importance of hand hygiene in preventing the spread of influenza. Washing hands after activities like blowing the nose can help reduce the risk of transmitting the virus to others. Choices B, C, and D are incorrect as they do not reflect accurate understanding of influenza prevention measures.

5. Which term is best described as a systematic, rational method of planning and providing nursing care for individuals, families, groups, and communities?

• A. Assessment
• B. Nursing Process
• C. Diagnosis
• D. Implementation

Correct answer: B

Rationale: The correct answer is B: Nursing Process. The nursing process is a systematic, rational method that guides nurses in planning and delivering patient care. It involves a series of steps including assessment, diagnosis, planning, implementation, and evaluation. By utilizing the nursing process, nurses can provide individualized care tailored to the specific needs of patients, families, groups, and communities. Choice A, Assessment, is a step within the nursing process but does not encompass the entire process itself. Choice C, Diagnosis, is another step within the nursing process and focuses on identifying the patient's health problems. Choice D, Implementation, is also a step in the nursing process where the care plan is put into action, but it does not solely describe the entire systematic and rational method of planning and providing nursing care.

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