Nursing Elites

1. The nurse instructs a laboring client to use accelerated-blow breathing. The client begins to complain of tingling fingers and dizziness. What action should the nurse take?

• A. Administer oxygen by face mask.
• B. Notify the healthcare provider of the client's symptoms.
• C. Have the client breathe into her cupped hands.
• D. Check the client's blood pressure and fetal heart rate.

Correct answer: C

Rationale: Tingling fingers and dizziness are symptoms of hyperventilation, which can occur with accelerated-blow breathing. Instructing the client to breathe into her cupped hands can help rebreathe exhaled carbon dioxide, which can alleviate the symptoms by restoring the proper balance of oxygen and carbon dioxide in the blood. This intervention can be effective in managing the client's hyperventilation without the need for additional medical interventions at this point.

2. When assessing a client who is at 12-weeks gestation, the LPN/LVN recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes?

• A. At 16 weeks gestation.
• B. At 20 weeks gestation.
• C. At 24 weeks gestation.
• D. At 30 weeks gestation.

Correct answer: D

Rationale: The best time for the couple to attend childbirth preparation classes is around 30 weeks gestation, which is during the third trimester. Attending classes at this time allows the couple to learn essential information and skills as labor and delivery are approaching, maximizing the benefit of the classes. Option A is too early in the second trimester, and the couple might forget important details by the time labor approaches. Option B is also early in the second trimester, and attending later allows for better preparation. Option C is still in the second trimester, and waiting until the third trimester provides more practical knowledge closer to delivery.

3. During a routine first-trimester prenatal exam, a pregnant client tells the nurse that she has noticed an increase in vaginal discharge that is white, thin, and watery. Which action should the nurse implement?

• A. Recommend explaining the normal physiological changes during pregnancy.
• B. Notify the healthcare provider of the complaint.
• C. Inform her that this is a normal physiological change.
• D. Prepare to provide education on vaginal health.

Correct answer: C

Rationale: The increased vaginal discharge described by the pregnant client, which is white, thin, and watery, is a common physiological change during pregnancy. It is typically normal and attributed to hormonal fluctuations. The nurse should reassure the client that this type of discharge is expected during pregnancy and does not typically indicate an issue requiring medical intervention or treatment.

4. Upon arrival in the nursery, a newborn infant is breathing satisfactorily but appears dusky. What action should the LPN/LVN take first?

• A. Notify the healthcare provider immediately.
• B. Suction the infant's nares, then the oral cavity.
• C. Check the infant's oxygen saturation rate.
• D. Position the infant on the right side.

Correct answer: C

Rationale: The priority action in this scenario is to check the infant's oxygen saturation rate. This will provide crucial information on the infant's oxygen levels and the need for immediate oxygen therapy. Assessing oxygen saturation is essential in determining the severity of hypoxia and guiding further interventions to ensure adequate oxygenation. Option A is not the priority as immediate intervention related to oxygenation is needed before notifying the healthcare provider. Suctioning (Option B) may be necessary but should come after assessing oxygen saturation. Positioning the infant (Option D) does not address the immediate need to evaluate oxygen levels.

5. The nurse is caring for a one-year-old child following surgical correction of hypospadias. Which nursing action has the highest priority?

• A. Monitor urinary output
• B. Auscultate bowel sounds
• C. Observe appearance of stool
• D. Record percent of diet consumed

Correct answer: A

Rationale: In caring for a one-year-old child post hypospadias surgery, the highest priority action is to monitor urinary output. This is crucial to assess kidney function and ensure there are no complications following the surgical procedure. Auscultating bowel sounds, observing stool appearance, and recording diet consumption are important assessments too, but in this case, monitoring urinary output takes precedence due to the nature of the surgery and potential complications related to urinary function.

Similar Questions