Nursing Elites

1. A nurse is caring for her clients when her new admit arrives on the unit. What action by the nurse is most appropriate?

• A. Ask the nursing assistant to complete emptying the catheter bag and assess the new admission.
• B. Ask the nursing assistant to take vital signs on the new admit and begin the history until she can get there.
• C. Ask the graduate nurse on the floor to initiate the assessment process until she can get there.
• D. Ask the unit secretary to make the client and family comfortable until she can complete her present task.

Correct answer: C

Rationale: The most appropriate action for the nurse in this situation is to ask the graduate nurse on the floor to initiate the assessment process until she can arrive. Nursing assistants are not qualified to perform assessments, and the unit secretary's role does not involve client assessments. Delegating the assessment to the graduate nurse ensures that a qualified healthcare professional is evaluating the new admission, aligning with the nurse's responsibilities and providing appropriate care.

2. When discussing possible complications of pregnancy with a client, the nurse should explain that all of the following are symptoms of urinary tract infection (UTI). Which of the following is least indicative of UTI during pregnancy?

• A. low back pain
• B. urinary frequency
• C. GI distress
• D. malaise

Correct answer: B

Rationale: Urinary frequency is least indicative of UTI during pregnancy. It is a common minor discomfort of pregnancy caused by pressure of the growing uterus on the bladder. As the uterus rises in the second trimester, there are usually no problems. Frequency may return in the third trimester when the uterus drops into the pelvic cavity. UTI symptoms include low back pain, suprapubic discomfort, and malaise, and are confirmed by laboratory findings. Low back pain, GI distress, and malaise are more closely associated with UTI during pregnancy compared to urinary frequency.

3. Which deficiency in the mother has been primarily associated with neural tube defects in the fetus?

• A. Iron
• B. Folic acid
• C. Vitamin B12
• D. Vitamin E

Correct answer: B

Rationale: Folic acid deficiency in the mother has been primarily associated with neural tube defects in the fetus. Folic acid is crucial for the development of the neural tube in the early stages of pregnancy. Its deficiency can lead to neural tube defects, such as spina bifida or anencephaly. Iron deficiency is not directly related to neural tube defects but can cause other complications in pregnancy. Vitamin B12 is important for neurological function but is not the primary cause of neural tube defects. Vitamin E deficiency is not associated with neural tube defects in the fetus.

4. Which of the following needs immediate medical attention and emergency intervention? The client who:

• A. complains of sharp pain upon taking a deep breath and excessive coughing.
• B. exhibits yellow, productive sputum, low-grade fever, and crackles.
• C. has a shift of the trachea to the left, with no breath sounds on the right.
• D. has asthma and complains of an inability to catch her breath after exercise.

Correct answer: C

Rationale: Choice C is indicative of a tension pneumothorax, which is considered a medical emergency. The respiratory system is severely compromised, and venous return to the heart is affected. The mediastinal shift is to the unaffected side, indicating a critical situation that requires immediate intervention to prevent further deterioration. This condition can rapidly progress to a life-threatening state, necessitating prompt medical attention. Choices A, B, and D do not present with life-threatening conditions requiring emergency intervention. Choice A mentions symptoms of pleurisy, which may be painful but not immediately life-threatening. Choice B describes symptoms of bronchitis, which may require medical attention but not of an emergent nature. Choice D reflects a common complaint in asthma but does not suggest an immediate life-threatening situation unless severe respiratory distress is present.

5. What is the best lab test to diagnose disseminated intravascular coagulation (DIC)?

• A. platelet count
• B. prothrombin time (PT)
• C. partial thromboplastin time (PTT)
• D. D-dimer

Correct answer: D

Rationale: The best lab test to diagnose disseminated intravascular coagulation (DIC) is the D-dimer test. In DIC, numerous small clots form throughout the body and are rapidly broken down. D-dimer measures a specific fibrin split product and is the most specific test for DIC. Platelet count (Choice A) is decreased in DIC due to consumption, but it is not specific for diagnosing DIC. Prothrombin time (PT - Choice B) and partial thromboplastin time (PTT - Choice C) are both elevated in DIC because clotting factors have been used up, but they are not specific for DIC as they can be elevated in other conditions as well.

Similar Questions