Nursing Elites

1. A nurse is caring for a client who is postpartum and reports perineal pain. Which intervention should the nurse implement?

• A. Administer analgesics as prescribed.
• B. Apply a warm compress to the perineum.
• C. Encourage the client to ambulate frequently.
• D. Position the client with the head elevated.

Correct answer: A

Rationale: Administering analgesics as prescribed is the appropriate intervention for managing perineal pain in a postpartum client. Analgesics help to alleviate discomfort and promote the client's recovery. Applying a warm compress (choice B) may provide some relief, but it does not address the pain as effectively as analgesics. Encouraging ambulation (choice C) and positioning the client with the head elevated (choice D) are not directly related to addressing perineal pain.

2. A nurse is assessing a client who has pericarditis. Which of the following findings is the priority?

• A. Paradoxical pulse
• B. Dependent edema
• C. Pericardial friction rub
• D. Substernal chest pain

Correct answer: A

Rationale: In a client with pericarditis, the priority finding is a paradoxical pulse. This is a crucial sign of cardiac tamponade, a life-threatening complication of pericarditis where fluid accumulates in the pericardial sac, causing compression of the heart. A paradoxical pulse is an exaggerated decrease in systolic blood pressure (>10 mmHg) during inspiration. Prompt recognition and intervention are essential to prevent hemodynamic instability and cardiac arrest. Dependent edema (choice B) is not typically associated with pericarditis. Pericardial friction rub (choice C) is a common finding in pericarditis but does not indicate the urgency of intervention as a paradoxical pulse. Substernal chest pain (choice D) is a classic symptom of pericarditis but is not as critical as a paradoxical pulse in the context of assessing for complications.

3. A nurse is assessing a client who has heart failure and is receiving furosemide. Which of the following findings should the nurse identify as an indication that the client is developing hypokalemia?

• A. Positive Trousseau's sign.
• B. Hyperactive reflexes.
• C. Hypoactive bowel sounds.
• D. Decreased deep-tendon reflexes.

Correct answer: A

Rationale: The correct answer is A: Positive Trousseau's sign. When a patient receiving furosemide is developing hypokalemia, they may exhibit a positive Trousseau's sign, an indication of low potassium levels. This sign is elicited by inflating a blood pressure cuff above systolic pressure for a few minutes, resulting in carpal spasm. Choices B, C, and D are incorrect. Hyperactive reflexes are associated with hyperkalemia, not hypokalemia. Hypoactive bowel sounds are not specifically related to hypokalemia. Decreased deep-tendon reflexes are not typically seen in hypokalemia.

4. A nurse is preparing to mix NPH and regular insulin in the same syringe. Which of the following actions should the nurse take?

• A. Inject air into the NPH insulin vial.
• B. Withdraw the prescribed dose of regular insulin.
• C. Withdraw the prescribed dose of NPH insulin.
• D. Mix the two insulins in separate syringes.

Correct answer: A

Rationale: When mixing NPH and regular insulin in the same syringe, the nurse should first inject air into the NPH insulin vial. This action prevents contamination by allowing an easier withdrawal of the correct dose of NPH insulin after withdrawing the regular insulin. Withdrawing the prescribed dose of regular insulin (Choice B) is incorrect as it does not address the initial step of injecting air into the NPH vial. Similarly, withdrawing the prescribed dose of NPH insulin (Choice C) is incorrect as it skips the crucial first step. Mixing the two insulins in separate syringes (Choice D) is not ideal since combining them in one syringe is a common practice to reduce the number of injections for the patient.

5. A nurse in a provider's office is reviewing the laboratory results of a group of clients. Which result is reportable?

• A. Herpes simplex
• B. Human papillomavirus
• C. Candidiasis
• D. Chlamydia

Correct answer: D

Rationale: Chlamydia is a reportable sexually transmitted infection. Reporting cases of Chlamydia to the health department is crucial for disease surveillance, contact tracing, and implementing public health interventions. Herpes simplex, human papillomavirus, and candidiasis are not typically reportable infections, as they do not pose the same public health risks as Chlamydia.

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