Nursing Elites

1. A nurse is preparing to perform a sterile dressing change for a client who has a surgical wound. Which of the following actions should the nurse take to prevent contamination during the dressing change?

• A. Use sterile gloves only as necessary
• B. Restart the procedure if the sterile solution splashes onto the sterile field while pouring the solution into the dressing tray
• C. Keep the dressing tray on a nearby surface
• D. Avoid speaking during the procedure

Correct answer: B

Rationale: The correct action to prevent contamination during a sterile dressing change is to restart the procedure if the sterile solution splashes onto the sterile field while pouring the solution into the dressing tray. Any contact with the sterile field by non-sterile items makes the field contaminated and requires restarting the procedure to maintain sterility. Choice A is incorrect because sterile gloves should always be used during a sterile procedure to prevent contamination. Choice C is incorrect as the dressing tray should be placed on a sterile surface, not on the client's bed, to maintain sterility. Choice D is also incorrect as talking during the procedure does not necessarily lead to contamination if proper aseptic technique is maintained.

2. A nurse is caring for a client in active labor. The nurse notes variable decelerations in the fetal heart rate. Which of the following is the priority nursing action?

• A. Administer oxygen
• B. Reposition the client
• C. Prepare for delivery
• D. Increase IV fluids

Correct answer: B

Rationale: The correct answer is to reposition the client. Variable decelerations are often caused by umbilical cord compression. Repositioning the client can help alleviate pressure on the cord and improve fetal oxygenation. Administering oxygen may be necessary in some situations, but repositioning the client takes precedence to address the underlying cause of variable decelerations. While preparing for delivery is important, addressing the immediate concern of variable decelerations by repositioning the client is the priority. Increasing IV fluids is not the priority in this situation as it does not directly address the cause of variable decelerations.

3. A nurse is reviewing a laboratory report for a client who is at 33 weeks of gestation and has preeclampsia. Which of the following laboratory results should the nurse report to the provider?

• A. BUN 35 mg/dL
• B. Hgb 15 g/dL
• C. Bilirubin 0.6 mg/dL
• D. Hct 37%

Correct answer: A

Rationale: A BUN of 35 mg/dL indicates potential kidney impairment, which is a concern in preeclampsia due to compromised renal function. This finding warrants further evaluation by the provider. High BUN levels may suggest reduced kidney function, a common complication associated with preeclampsia. Hgb, Bilirubin, and Hct levels are within normal ranges and are not directly indicative of kidney impairment or preeclampsia in this scenario. Therefore, the nurse should report the elevated BUN level to the healthcare provider for prompt management and monitoring.

4. A healthcare professional is assessing a client who is experiencing a thyroid storm. Which of the following is an expected finding?

• A. Hypothermia
• B. Bradycardia
• C. Hypertension
• D. Lethargy

Correct answer: C

Rationale: In a thyroid storm, which is a severe complication of hyperthyroidism, hypertension is an expected finding. Other common manifestations include tachycardia, hyperthermia, and agitation. Hypothermia (choice A) is not expected in a thyroid storm as the body temperature is usually elevated due to increased metabolic rate. Bradycardia (choice B) is not typical in a thyroid storm; instead, tachycardia is more common. Lethargy (choice D) is not a typical finding in a thyroid storm, as clients are usually agitated due to excess thyroid hormone levels.

5. A nurse is reviewing laboratory results for a client receiving chemotherapy. Which result should the nurse report to the provider?

• A. WBC 3,000/mm³
• B. Hemoglobin 12 g/dL
• C. Platelet count 250,000/mm³
• D. Serum sodium 140 mEq/L

Correct answer: A

Rationale: The correct answer is A: WBC 3,000/mm³. A WBC count of 3,000/mm³ indicates neutropenia, which is a condition characterized by a low level of white blood cells, specifically neutrophils. Neutropenia increases the risk of infection and requires immediate medical attention, especially in clients undergoing chemotherapy. Reporting this result to the provider promptly is crucial for further evaluation and intervention. Choices B, C, and D are within normal ranges and do not pose an immediate risk to the client's health. Hemoglobin of 12 g/dL, platelet count of 250,000/mm³, and serum sodium of 140 mEq/L are all normal values and would not typically require immediate reporting unless there are specific concerns related to the individual client's condition.

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