Nursing Elites

1. A nurse overhears two assistive personnel (AP) discussing care for a client in the elevator. What action should the nurse take?

• A. Contact the client's family about the incident.
• B. Notify the client's provider about the incident.
• C. File a complaint with the ethics committee.
• D. Report the incident to the AP's charge nurse.

Correct answer: D

Rationale: The correct action for the nurse to take in this situation is to report the incident to the AP's charge nurse. This ensures that the issue is addressed internally and allows for proper handling of the situation. Contacting the client's family about the incident (Choice A) may not be appropriate as it could breach confidentiality and escalate the situation unnecessarily. Notifying the client's provider (Choice B) is not the most immediate and effective step to address the issue. Filing a complaint with the ethics committee (Choice C) should be reserved for serious ethical violations, and in this case, reporting to the charge nurse is the more practical and immediate course of action.

2. While reviewing the monitor tracing of a client in labor, a nurse notes late decelerations. Which of the following interventions should the nurse perform?

• A. Administer oxygen via nasal cannula
• B. Reposition the client onto her left side
• C. Administer an amnioinfusion
• D. Provide reassurance to the client

Correct answer: B

Rationale: Repositioning the client onto her left side is the appropriate intervention when late decelerations are noted on the monitor tracing. This action helps increase uteroplacental blood flow by relieving pressure on the vena cava and aorta, improving fetal oxygenation. Administering oxygen via nasal cannula may be indicated for variable decelerations, not late decelerations. Administering an amnioinfusion is not the primary intervention for late decelerations. Providing reassurance to the client is important but addressing the underlying cause of late decelerations takes precedence.

3. A client is 4 hours postpartum. Which of the following interventions should be implemented to prevent postpartum hemorrhage?

• A. Monitor for signs of infection.
• B. Massage the uterus every 4 hours.
• C. Apply ice packs to the perineum.
• D. Administer methylergonovine IM.

Correct answer: D

Rationale: Administering methylergonovine intramuscularly helps contract the uterus, reducing the risk of postpartum hemorrhage. Monitoring for signs of infection (Choice A) is important but not directly related to preventing postpartum hemorrhage. Uterine massage (Choice B) is beneficial to prevent uterine atony, but methylergonovine is a more specific intervention to prevent hemorrhage. Applying ice packs to the perineum (Choice C) is helpful for perineal pain and swelling, not for preventing postpartum hemorrhage.

4. Nurses caring for four clients. Which of the following client data should the nurse report to the provider?

• A. A client who has pleurisy and reports pain of 6 on a scale of 0 to 10 when coughing
• B. Client drained a total of 110 mL of serosanguineous fluid from the Jackson Pratt drain within the first 24 hours following surgery
• C. Client who is 4 hours postoperative and has a heart rate of 98 per minute
• D. The client has a prescription for chemotherapy and an absolute neutrophil count of 75/mm3

Correct answer: D

Rationale: The correct answer is D. The client with chemotherapy and a low neutrophil count is at risk for infection and requires prompt intervention. Reporting this information to the provider is crucial to ensure appropriate monitoring and management to prevent potential complications. Choices A, B, and C do not indicate an immediate risk that requires immediate provider notification. A client reporting pain with pleurisy, a client draining fluid post-surgery, or a client with a heart rate of 98 per minute postoperative are not urgent enough to warrant immediate reporting compared to the client at risk for infection.

5. A nurse is providing discharge teaching to a client who has a new prescription for warfarin. Which of the following client statements indicates an understanding of the teaching?

• A. I will need to have my INR checked regularly while taking this medication.
• B. I should avoid eating leafy green vegetables while taking this medication.
• C. I will stop taking this medication if I experience nausea.
• D. I will avoid taking aspirin while taking this medication.

Correct answer: A

Rationale: The correct answer is A because clients taking warfarin should have their INR (International Normalized Ratio) checked regularly to monitor the medication's effectiveness and adjust the dose if needed. This monitoring helps to ensure the medication is working correctly and the client is within the therapeutic range. Choice B is incorrect because clients on warfarin should not avoid leafy green vegetables but should maintain a consistent intake. Leafy green vegetables contain vitamin K, which can affect warfarin, so it's important to maintain a consistent intake to keep INR stable. Choice C is incorrect as clients should not stop taking warfarin abruptly without consulting their healthcare provider as it can lead to serious health risks like blood clots. Choice D is incorrect because while taking warfarin, it is important to avoid unnecessary aspirin use due to an increased risk of bleeding. However, this statement does not indicate an understanding of the teaching about the need for regular INR monitoring.

Similar Questions