Nursing Elites

1. A nurse is supervising a student in preparing the physical environment for an interview with a client. Which action by the student is correct?

• A. Setting the room temperature at a comfortable level
• B. Placing a chair for the client across from the nurse's desk
• C. Providing seating for the client so that the client faces a strong light
• D. Setting up seating so that the client and nurse are not at eye level

Correct answer: A

Rationale: When preparing the physical environment for an interview with a client, it is crucial to ensure the client's comfort. Setting the room temperature at a comfortable level is essential for the client's well-being. Additionally, providing privacy, sufficient lighting, and removing distractions are crucial factors. It is recommended to maintain a distance of around 4 to 5 feet between the client and the nurse. Seating should be arranged so that the client and nurse are at eye level to facilitate effective communication and prevent barriers. Placing a chair across from the nurse's desk may create a physical barrier, positioning the client to face a strong light can be uncomfortable and distracting, and setting up seating so that the client and nurse are not at eye level may impede effective communication.

2. The greatest time savers when planning client care include all of the following except:

• A. reacting to the crisis of the moment
• B. setting goals
• C. planning
• D. specifying priorities

Correct answer: A

Rationale: The greatest time-savers when planning client care are activities that facilitate focus and completion of priority items. Time-savers include setting goals, specifying priorities, planning tasks, delegating where appropriate, reassessment, and ongoing evaluation of needs. Reacting to the crisis of the moment is not a time-saving strategy in client care planning; it can lead to inefficiency, lack of focus, and potentially missing important priority items. Therefore, the correct answer is 'reacting to the crisis of the moment.' Choices B, C, and D are essential components for effective client care planning as they help in organizing and prioritizing tasks, setting objectives, and ensuring a structured approach to care delivery.

3. A nurse notes the presence of variable decelerations on the fetal heart rate monitor strip and suspects cord compression. The nurse should immediately perform which action?

• A. Insert a gloved finger into the mother's vagina to feel for cord compression
• B. Position the mother so that her hips are elevated
• C. Notify the registered nurse
• D. Perform a vaginal examination on the mother

Correct answer: B

Rationale: When variable decelerations on the fetal heart rate monitor strip suggest cord compression, the immediate action the nurse should take is to reposition the mother to alleviate the compression. Elevating the mother's hips or changing her position can help shift the fetal presenting part and relieve pressure on the cord. This action aims to improve or resolve the variable decelerations. Contacting the registered nurse may be necessary, but it is not the immediate action required in this situation. Performing a vaginal examination is contraindicated due to the potential risk of further compromising blood flow through the umbilical cord. Inserting a gloved finger into the mother's vagina to feel for the cord is also not recommended as it poses a similar risk of exacerbating the situation.

4. A client turns her ankle. She is diagnosed as having a Pulled Ligament. This should be documented as a:

• A. sprain.
• B. strain.
• C. subluxation.
• D. dislocation.

Correct answer: B

Rationale: The term 'strain' is the correct choice. A strain refers to the excessive stretching of a muscle or tendon, which aligns with a pulled ligament diagnosis. A sprain, on the other hand, involves ligament injury due to twisting motions. 'Subluxation' indicates a partial dislocation of a joint, not a pulled ligament. 'Dislocation' refers to the complete displacement of bones in a joint, which is not the appropriate term for a pulled ligament.

5. While taking the vital signs of a pregnant client admitted to the labor unit, a nurse notes a temperature of 100.6�F, pulse rate of 100 beats/min, and respirations of 24 breaths/min. What is the most appropriate nursing action based on these findings?

• A. Notify the registered nurse of the findings.
• B. Document the findings in the client's medical record.
• C. Recheck the vital signs in 1 hour.
• D. Continue collecting subjective and objective data.

Correct answer: A

Rationale: The correct answer is to notify the registered nurse of the findings. In a pregnant client, the normal temperature range is 98�F to 99.6�F, with a pulse rate of 60 to 90 beats/min and respirations of 12 to 20 breaths/min. A temperature of 100.4�F or higher, along with an increased pulse rate and faster respirations, suggests a possible infection. Immediate notification of the registered nurse is crucial for further evaluation and intervention. While documenting the findings is essential, the priority lies in promptly escalating abnormal vital signs for assessment and management. Rechecking vital signs in 1 hour may delay necessary interventions for a deteriorating condition. Continuing to collect data is relevant but should not delay informing the registered nurse when abnormal vital signs are present.

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