Nursing Elites

1. At 14-weeks gestation, a client arrives at the Emergency Center complaining of a dull pain in the right lower quadrant of her abdomen. The LPN/LVN obtains a blood sample and initiates an IV. Thirty minutes after admission, the client reports feeling a sharp abdominal pain and shoulder pain. Assessment findings include diaphoresis, a heart rate of 120 beats/minute, and a blood pressure of 86/48. Which action should the nurse implement next?

• A. Check the hematocrit results.
• B. Administer pain medication.
• C. Increase the rate of IV fluids.
• D. Monitor the client for contractions.

Correct answer: C

Rationale: The client's symptoms suggest hypovolemic shock, possibly due to an ectopic pregnancy. Increasing IV fluids is crucial to stabilize the client by improving blood pressure and perfusion. This intervention helps address the underlying issue of hypovolemia and supports the client's hemodynamic status, which takes priority in this emergent situation.

2. After a full-term vaginal delivery, a postpartum client's white blood cell count is 15,000/mm3. What action should the nurse take first?

• A. Check the differential, as the WBC count can be normal for this client.
• B. Assess the client's temperature, pulse, and respirations every 4 hours.
• C. Notify the healthcare provider, as this finding may indicate infection.
• D. Assess the client's perineal area for signs of a perineal hematoma.

Correct answer: A

Rationale: In postpartum clients, a white blood cell count of 15,000/mm3 can be within normal limits due to physiological changes that occur after childbirth. Checking the differential count would provide a more detailed analysis of the specific types of white blood cells present, helping to differentiate between normal postpartum changes and potential infection. This action allows the nurse to gather more information before escalating the situation to the healthcare provider or initiating other assessments. Assessing vital signs and the perineal area are important aspects of postpartum care but may not be the priority in this scenario where the white blood cell count can be influenced by normal physiological changes.

3. A client at 18-weeks gestation was informed this morning that she has an elevated alpha-fetoprotein (AFP) level. After the healthcare provider leaves the room, the client asks what she should do next. What information should the nurse provide?

• A. Inform her that a repeat alpha-fetoprotein (AFP) should be evaluated.
• B. Discuss options for intrauterine surgical correction of congenital defects.
• C. Reassure the client that the AFP results are likely to be a false reading.
• D. Explain that a sonogram should be scheduled for definitive results.

Correct answer: D

Rationale: An elevated alpha-fetoprotein (AFP) level in a pregnant client can indicate potential congenital anomalies in the fetus. A follow-up sonogram is necessary to provide definitive results and further evaluate the fetus for any possible abnormalities. Therefore, it is essential for the nurse to explain to the client that scheduling a sonogram is the next appropriate step to assess the fetal well-being and address any concerns regarding the elevated AFP level. Choices A, B, and C are incorrect because a repeat AFP test alone, discussing surgical correction of defects, or assuming the results are false without further evaluation are not appropriate responses when dealing with a potentially serious issue like elevated AFP levels in pregnancy.

4. A mother calls the school nurse to report that her preschool-aged child was bitten by a tick during a school outing last week. The mother removed the tick and flushed it down the toilet. What action should the school nurse take?

• A. Refer the mother to the Centers for Disease Control and Prevention.
• B. Report the incident to the school principal.
• C. Culture the bite site when the child returns to school.
• D. Schedule a test for Lyme disease if a rash appears.

Correct answer: D

Rationale: The correct action to take in this situation is to schedule a test for Lyme disease if a rash appears. Lyme disease can be transmitted through tick bites, and a rash is a common early symptom of the disease. Testing for Lyme disease is crucial for timely diagnosis and treatment to prevent complications. Referring the mother to the Centers for Disease Control and Prevention (Choice A) is not necessary at this point, as immediate testing for Lyme disease is more appropriate. Reporting the incident to the school principal (Choice B) is not the most direct action to address the potential health concern. Culturing the bite site when the child returns to school (Choice C) may not be as effective as scheduling a test for Lyme disease if a rash appears, as the latter is a more specific diagnostic measure for Lyme disease.

5. In caring for a 4-year-old boy recently diagnosed with Duchenne muscular dystrophy (DMD), which characteristic of the disease is most important for the nurse to focus on during the initial teaching?

• A. Lower legs become progressively weaker, causing a waddling, unsteady gait.
• B. Growth and development have been abnormal since birth.
• C. Muscular strength can be regained with physical exercise and therapy.
• D. Respiratory dysfunction and aspiration are prime concerns at this stage of the disease.

Correct answer: A

Rationale: In Duchenne muscular dystrophy, a key characteristic is the progressive weakness in the lower legs, leading to a waddling, unsteady gait. The nurse should focus on teaching about this aspect as it helps in understanding the disease's progression and managing the symptoms effectively.

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