Nursing Elites

1. A postpartum client's fundus is firm, 3 cm above the umbilicus, and displaced to the right. Which of the following interventions should the nurse take?

• A. Massage the fundus
• B. Administer oxytocin
• C. Assist the client to void then reassess the fundus
• D. Notify the healthcare provider

Correct answer: C

Rationale: The correct intervention for a postpartum client with a firm, displaced fundus is to assist the client to void then reassess the fundus. Displacement of the uterus to the right is often a sign of bladder distention, which can prevent the uterus from contracting properly and increase the risk of postpartum hemorrhage. By helping the client to void, the nurse can alleviate the bladder distention, allowing the uterus to contract effectively. Massaging the fundus (Choice A) may not address the underlying issue of bladder distention. Administering oxytocin (Choice B) is not indicated without assessing and addressing the cause of the displacement. Notifying the healthcare provider (Choice D) is premature before implementing initial nursing interventions to address the potential cause of the displaced fundus.

2. A nurse enters a client's room and sees smoke coming from the trash can. Which of the following actions should the nurse take first?

• A. Close the window
• B. Evacuate the room
• C. Call the fire department
• D. Attempt to extinguish the fire

Correct answer: B

Rationale: The correct answer is to evacuate the room first. In a fire situation, the priority is safety, following the RACE protocol: Rescue, Alarm, Contain, Extinguish. Evacuating the room ensures the safety of both the client and the nurse. Closing the window (Choice A) can wait until after evacuation when there is no immediate danger. Calling the fire department (Choice C) is important but comes after ensuring personal safety and evacuating. Attempting to extinguish the fire (Choice D) is not recommended as it can put the nurse and the client at risk; firefighting should be left to professionals.

3. A charge nurse discovers that a nurse did not notify the provider that a client's condition had changed. The charge nurse should identify that the nurse is accountable for which of the following torts?

• A. Assault
• B. Battery
• C. Negligence
• D. False imprisonment

Correct answer: C

Rationale: The correct answer is C: Negligence. Negligence refers to the failure to take reasonable care or fulfill a duty, which can cause harm to others. In this scenario, the nurse's failure to notify the provider of a change in the client's condition constitutes negligence as it breaches the standard of care expected in healthcare practice. Choice A, Assault, involves the threat of harmful or offensive contact, which is not applicable in this situation. Choice B, Battery, refers to the intentional harmful or offensive touching of another person without their consent, which is also not relevant here. Choice D, False imprisonment, involves the intentional confinement or restraint of an individual against their will, which is not the issue described in the scenario. Therefore, the most appropriate tort in this case is negligence.

4. A nurse receives a change-of-shift report. Which of the following clients should the nurse attend to first?

• A. A client who reports tingling in the fingers following a thyroidectomy
• B. A client who has dark, foul-smelling urine with a urine output of 320 mL in the last 8 hr
• C. A client who is in a long leg cast and reports cool feet bilaterally
• D. A client who has a productive cough and an oral temperature of 36°C (96.8°F)

Correct answer: C

Rationale: The correct answer is C. Cool feet bilaterally in a client with a long leg cast may indicate compromised circulation, which is a medical emergency that requires immediate intervention. Choices A, B, and D do not present immediate life-threatening conditions. Tingling in the fingers following a thyroidectomy may indicate hypocalcemia but does not require immediate attention. Dark, foul-smelling urine with decreased urine output indicates a possible urinary tract infection or dehydration but can be addressed after attending to the client with compromised circulation. A productive cough and a normal oral temperature do not suggest an urgent condition compared to compromised circulation in a client with a long leg cast.

5. A client is being educated by a nurse about the use of carbidopa-levodopa. Which of the following should be included?

• A. It will cure Parkinson's disease
• B. Monitor for dyskinesia
• C. It can be taken with food
• D. It is an opioid medication

Correct answer: B

Rationale: The correct answer is to 'Monitor for dyskinesia.' Carbidopa-levodopa can cause dyskinesia as a side effect, characterized by involuntary movements. Monitoring for this side effect is crucial. Choice A is incorrect because carbidopa-levodopa helps manage symptoms of Parkinson's disease but does not cure it. Choice C is incorrect because carbidopa-levodopa should be taken on an empty stomach to enhance absorption. Choice D is incorrect because carbidopa-levodopa is not an opioid medication.

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