Nursing Elites

1. A nurse manager is reviewing documentation with a newly licensed nurse. Which of the following notations by the newly licensed nurse indicates an understanding of the teaching?

• A. ''OOB with assistance for breakfast''
• B. ''Given 2 mg MSO4 IM for report of pain''
• C. ''Dressing changed qd''
• D. ''Administered 8 units of regular insulin subcutaneously''

Correct answer: D

Rationale: The correct answer demonstrates proper documentation by specifying the action taken ('Administered'), the dose ('8 units'), the medication ('regular insulin'), and the route of administration ('subcutaneously'). This notation ensures clarity and accuracy in recording the nursing intervention, aligning with best practices in documentation.

2. During a shift change, a nurse is receiving a report for an adult female client who is postoperative. Which of the following client information should the nurse report?

• A. High platelets
• B. Hypertension
• C. Lower platelets
• D. High temperatures

Correct answer: C

Rationale: Lower platelets can indicate a potential risk of bleeding in a postoperative client. Thrombocytopenia, or low platelet count, can lead to increased bleeding tendencies and should be promptly reported to the healthcare team for appropriate management. Monitoring platelet levels is crucial in postoperative care to prevent complications related to inadequate clotting ability.

3. 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.

4. A client has a new prescription for heparin therapy. Which of the following statements by the client should indicate an immediate concern for the nurse?

• A. ''I am allergic to morphine.''
• B. ''I take antacids several times a day.''
• C. ''I had a blood clot in my leg several years ago.''
• D. ''It hurts to take a deep breath.''

Correct answer: B

Rationale: The correct answer is the statement 'I take antacids several times a day.' Antacids can alter the absorption of heparin, potentially affecting its effectiveness and increasing the risk of clot formation. This is a significant concern as it can impact the therapeutic outcome of heparin therapy. The other statements are not directly related to potential complications or interactions with heparin therapy.

5. What is a muscular enlarged pouch or sac that lies slightly to the left and is used for the temporary storage of food?

• A. Gallbladder
• B. Urinary bladder
• C. Stomach
• D. Lungs

Correct answer: C

Rationale: The correct answer is the stomach. The stomach is a muscular organ located slightly to the left in the abdominal cavity. It serves as a temporary storage site for food where it is mixed with digestive enzymes and acids to begin the process of digestion. The gallbladder (Choice A) is not involved in food storage; it stores bile produced by the liver. The urinary bladder (Choice B) is part of the urinary system and stores urine. The lungs (Choice D) are responsible for respiration, not food storage.

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