Nursing Elites

1. A primigravida at term comes to the prenatal clinic and tells the nurse that she is having contractions every 5 min. The nurse monitors the client for one hour, using an external fetal monitor, and determines that the client’s contractions are 7 to 15 minutes apart, lasting 20 to 30 seconds, with mild intensity by palpation. What action should the nurse take?

• A. Tell the client to go directly to the hospital for admission to labor and delivery for active labor
• B. Send the client home and instruct her to call the clinic when her contractions occur 5 minutes apart for one hour
• C. Tell the client to check into the hospital within the next hour for evaluation of possible urinary tract infection
• D. Advise the client to rest and hydrate, then return if contractions become more regular

Correct answer: B

Rationale: The client should be instructed to call when contractions are 5 minutes apart for an hour to ensure she is in active labor before going to the hospital.

2. The nurse is assessing a client who is 2 days post-op following abdominal surgery. The client reports feeling something 'give way' in the incision site and there is a small amount of bowel protruding from the wound. What action should the nurse take first?

• A. Apply a sterile saline dressing to the wound
• B. Notify the healthcare provider
• C. Administer pain medication
• D. Cover the wound with an abdominal binder

Correct answer: A

Rationale: In this scenario, the nurse should first apply a sterile saline dressing to the wound. This action helps prevent infection and keeps the wound moist, which is crucial in promoting healing. Option B, notifying the healthcare provider, is important but should come after providing immediate wound care. Option C, administering pain medication, is not the priority when there is a small amount of bowel protruding from the wound. Option D, covering the wound with an abdominal binder, is not appropriate for this situation as it does not address the protruding bowel and potential risk for infection.

3. The nurse is planning care for a client who is receiving radiation therapy for breast cancer. Which intervention is most important for the nurse to include?

• A. Encourage the client to use sunscreen
• B. Apply lotion to the radiated area
• C. Keep the area dry and clean
• D. Encourage the client to exercise the arm

Correct answer: C

Rationale: Keeping the radiated area dry and clean is crucial to prevent skin irritation and infection. Radiation therapy can cause skin changes, making it susceptible to irritation and infection. Using sunscreen (Choice A) is not usually recommended on the radiated area as it can further irritate the skin. Applying lotion (Choice B) may not be suitable as it can trap moisture and cause skin breakdown. While encouraging exercise (Choice D) is important, keeping the area dry and clean takes precedence to prevent complications during radiation therapy.

4. The husband and adult children of a woman who abuses alcohol ask the nurse what approach to use when her drinking behavior disrupts family plans. Which response is best for the nurse to provide?

• A. Destroy any hidden supplies of alcohol she has at home so she has to stay sober
• B. When she drinks, communicate how disruptive her behaviors are and the burden they inflict on the family
• C. Make her responsible for the consequences of her drinking behaviors
• D. Include her in family activities whether she is drinking or sober

Correct answer: C

Rationale: The best approach for the nurse to suggest is to make the woman responsible for the consequences of her drinking behaviors. By holding her accountable, she is more likely to recognize the impact of her actions and potentially initiate change. Destroying hidden alcohol supplies (Choice A) might lead to conflict and further secretive behavior. Simply communicating the disruptions caused by her drinking (Choice B) may not effectively address the issue. Including her in family activities regardless of her drinking status (Choice D) could enable the behavior and not address the underlying problem.

5. The nurse is administering total parenteral nutrition (TPN) via a central line at 75 ml/hour to a client who had a bowel resection 4 days ago. Which laboratory finding requires the most immediate intervention by the nurse?

• A. Blood glucose of 140 mg/dL
• B. White blood cell count of 8000/mm³
• C. Serum potassium of 3.8 mEq/L
• D. Serum calcium of 7.8 mg/dL

Correct answer: D

Rationale: The correct answer is D. A serum calcium level of 7.8 mg/dL requires immediate intervention due to the risk of hypocalcemia. Hypocalcemia can lead to serious complications such as tetany, seizures, and cardiac arrhythmias. The other laboratory findings are within normal limits or slightly elevated, which do not pose an immediate threat to the client's health in this scenario.

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