Nursing Elites

1. A woman who is breastfeeding calls her obstetrician’s office and reports increased anxiety since the vaginal delivery of her son three weeks ago. She stopped taking her antianxiety medications but is thinking of restarting them. What response should the nurse provide?

• A. Describe the potential transmission of drugs to the infant through breast milk.
• B. Encourage her to utilize stress-relieving alternatives, such as deep breathing.
• C. Explain that anxiety is a common reaction for mothers of 3-week-old infants.
• D. Inform her that some antianxiety medications are safe to take while breastfeeding.

Correct answer: D

Rationale: The correct answer is D because some antianxiety medications are considered safe during breastfeeding. The nurse should reassure the client and encourage her to discuss options with her healthcare provider to manage anxiety safely while continuing to breastfeed. Choice A is incorrect because it focuses on the transmission of drugs rather than providing guidance on safe medication use. Choice B, while promoting stress-relieving techniques, does not address the potential need for medication. Choice C is incorrect as it minimizes the woman's reported anxiety, which may require professional intervention.

2. After a spider bite on the lower extremity, a client is admitted to treat an infection that is spreading up the leg. Which admission assessment findings should the nurse report to the healthcare provider?

• A. Swollen lymph nodes in the groin
• B. Core body temperature of 100.5°F
• C. All of the above
• D. Elevated white blood cell count

Correct answer: C

Rationale: All of the above findings should be reported to the healthcare provider for prompt evaluation and treatment. Swollen lymph nodes in the groin indicate regional lymphatic involvement, a core body temperature of 100.5°F suggests a mild fever response, and an elevated white blood cell count indicates an ongoing infection process. These findings collectively point towards the spread of infection and require immediate attention to prevent further complications.

3. A nurse is caring for a client with a chest tube following lung surgery. What is the most important intervention to ensure the chest tube functions properly?

• A. Clamp the tube if there is excessive drainage
• B. Empty the drainage chamber every 2 hours
• C. Keep the drainage system below chest level
• D. Milk the tube to prevent clots from forming

Correct answer: C

Rationale: The correct answer is C. Keeping the chest tube drainage system below chest level ensures that gravity assists with drainage and prevents fluid or air from flowing back into the pleural space, which could compromise lung function. Clamping the tube if there is excessive drainage (choice A) is incorrect as it can lead to a buildup of pressure and compromise the drainage system. Emptying the drainage chamber every 2 hours (choice B) is important but not as crucial as maintaining the drainage system below chest level. Milking the tube to prevent clots from forming (choice D) is incorrect and could lead to complications such as tube occlusion or damage to the tissue.

4. A client is admitted with a large bowel obstruction. What finding should the nurse report immediately?

• A. Absence of bowel sounds in all four quadrants.
• B. Abdominal distention with a firm, rigid abdomen.
• C. Frequent, small, liquid stools.
• D. Nausea and vomiting that worsens after meals.

Correct answer: B

Rationale: Abdominal distention with a firm, rigid abdomen is a concerning sign that may indicate perforation, which requires immediate intervention. The rigidity suggests a complication of the large bowel obstruction. Absence of bowel sounds in all four quadrants, option A, is a common finding in a bowel obstruction but not as alarming as a rigid abdomen. Frequent, small, liquid stools, option C, are not typical findings in a large bowel obstruction; instead, constipation is more common. Nausea and vomiting that worsens after meals, option D, are also common symptoms of a bowel obstruction but do not indicate an immediate life-threatening complication like a perforation.

5. A client is receiving a blood transfusion and reports feeling chilled and short of breath. What is the nurse's priority action?

• A. Stop the transfusion and notify the healthcare provider.
• B. Administer an antihistamine as prescribed.
• C. Administer a dose of acetaminophen.
• D. Administer a PRN dose of diphenhydramine.

Correct answer: A

Rationale: The correct action for the nurse to take when a client receiving a blood transfusion reports feeling chilled and short of breath is to stop the transfusion immediately and notify the healthcare provider. These symptoms could indicate a transfusion reaction, which can be serious and even life-threatening. Stopping the transfusion is crucial to prevent further adverse reactions, and notifying the healthcare provider ensures timely intervention and appropriate management. Administering antihistamines, acetaminophen, or diphenhydramine is not the priority in this situation and may delay necessary actions to address the potential transfusion reaction.

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