Nursing Elites

1. A nurse on a postpartum unit is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?

• A. A client who gave birth 1 day ago and needs Rho(D) immune globulin
• B. A client who gave birth 3 days ago and reports breast fullness
• C. A client who gave birth 12 hours ago and reports an increase in urinary output
• D. A client who gave birth 8 hours ago and is saturating a perineal pad every hour

Correct answer: D

Rationale: The nurse should see the client saturating a perineal pad every hour first. This client may be experiencing postpartum hemorrhage, which is a medical emergency requiring immediate assessment and intervention. The other options describe clients with less urgent needs. The client needing Rho(D) immune globulin can wait, the breast fullness in the client who gave birth 3 days ago can be addressed after managing the postpartum hemorrhage, and an increase in urinary output in a client who gave birth 12 hours ago is not indicative of an immediate emergency like postpartum hemorrhage.

2. A nurse is planning care for a client who has Alzheimer's disease and demonstrates confusion and wandering behavior. Which of the following should the nurse include in the plan of care?

• A. Place the client in seclusion when she is confused
• B. Request a prescription for PRN restraints when the client is wandering
• C. Dim the lighting in the client’s room
• D. Leave one side rail up on the client's bed

Correct answer: D

Rationale: The correct answer is to leave one side rail up on the client's bed. This action can help prevent falls while allowing the client to get up safely when needed, reducing the risk of injury from wandering. Placing the client in seclusion (Choice A) is not appropriate as it can lead to increased agitation and distress. Requesting restraints (Choice B) should be avoided as it can increase the risk of injuries and is not recommended for clients with Alzheimer's. Dimming the lighting (Choice C) may increase confusion and disorientation in clients with Alzheimer's disease.

3. A nurse is caring for a client who is hyperventilating and has the following ABG results: pH 7.50, PaCO2 29 mm Hg, and HCO3- 25 mEq/L. The nurse should recognize that the client has which of the following acid-base imbalances?

• A. Respiratory acidosis
• B. Respiratory alkalosis
• C. Metabolic acidosis
• D. Metabolic alkalosis

Correct answer: B

Rationale: The correct answer is B: Respiratory alkalosis. In this scenario, the client is hyperventilating, leading to excessive elimination of carbon dioxide. As a result, the PaCO2 decreases, causing a decrease in hydrogen ion concentration and an increase in pH, resulting in respiratory alkalosis. Choice A, Respiratory acidosis, is incorrect because the ABG results show a low PaCO2, not an elevated one. Choices C and D, Metabolic acidosis and Metabolic alkalosis, do not align with the ABG results provided, which point towards a respiratory, not metabolic, imbalance.

4. A nurse is sitting with the partner of a client who recently died. Which action should the nurse take to facilitate mourning?

• A. Offer advice on coping strategies
• B. Encourage the partner to ask for help when needed
• C. Discuss the importance of grieving alone
• D. Suggest the partner avoid talking about the loss

Correct answer: B

Rationale: Encouraging the partner to ask for help when needed is the most appropriate action for the nurse to facilitate mourning. Grieving is a challenging process, and individuals may require support from others to cope effectively. Offering advice on coping strategies, discussing the importance of grieving alone, or suggesting avoiding talking about the loss could hinder the partner's mourning process by isolating them or suppressing their feelings.

5. A nurse is updating a plan of care after evaluating a client who has dysphagia. Which interventions should the nurse include in the plan?

• A. Have the client lie down after meals
• B. Encourage the client to speak while eating
• C. Have the client sit upright for 1 hour following meals
• D. Offer thin liquids with meals

Correct answer: C

Rationale: The correct intervention for a client with dysphagia is to have them sit upright for 1 hour following meals. This position facilitates swallowing and reduces the risk of aspiration. Choice A is incorrect because having the client lie down after meals can increase the risk of aspiration. Choice B is incorrect as talking while eating can lead to choking. Choice D is incorrect as thin liquids may be harder for a client with dysphagia to swallow safely.

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