Nursing Elites

1. What assessment technique should the nurse use to monitor a client for a common untoward effect of phenytoin (Dilantin)?

• A. Bladder palpation
• B. Inspection of the mouth
• C. Blood glucose monitoring
• D. Auscultation of breath sounds

Correct answer: B

Rationale: The correct answer is B: Inspection of the mouth. This assessment technique is crucial for monitoring gingival hyperplasia, a common side effect of phenytoin. Bladder palpation (choice A) is not relevant to monitoring for phenytoin's side effects. Blood glucose monitoring (choice C) is important for clients with diabetes but is not specifically related to phenytoin. Auscultation of breath sounds (choice D) is more relevant for assessing respiratory conditions, not side effects of phenytoin.

2. Nurses working in labor and delivery are demanding a change in policy because they believe they are required to float more often than nurses on other units. However, floating to labor and delivery is not reciprocated because other nurses are not competent to provide highly specialized obstetrical skills. What action is best for the nurse-manager to implement?

• A. Require cross-training for obstetrics for other nurses
• B. Propose a method for self-staffing labor and delivery
• C. Remind nurses that floating is an administrative policy
• D. Encourage nurses to share their feelings with administration

Correct answer: B

Rationale: The best action for the nurse-manager to implement is to propose a method for self-staffing labor and delivery. This approach allows nurses to manage their schedules, ensuring a fair balance of workloads. Requiring cross-training for obstetrics for other nurses (Choice A) may not be feasible or necessary for all units. Reminding nurses that floating is an administrative policy (Choice C) does not address the underlying issue of workload balance. Encouraging nurses to share their feelings with administration (Choice D) may not lead to a concrete solution for the unequal floating concerns.

3. An 18-year-old gravida 1, at 41-weeks gestation, is undergoing an oxytocin (Pitocin) induction and has an epidural catheter in place for pain control. With each of the last three contractions, the nurse notes a late deceleration. The client is repositioned and oxygen provided, but the late decelerations continue to occur with each contraction. What action should the nurse take first?

• A. Prepare for immediate cesarean birth
• B. Turn off the oxytocin (Pitocin) infusion
• C. Notify the anesthesiologist that the epidural infusion needs to be disconnected
• D. Apply an internal fetal monitoring device and continue to monitor carefully

Correct answer: B

Rationale: In the scenario described, the presence of late decelerations during contractions indicates fetal compromise. To address this, the nurse's initial action should be to turn off the oxytocin (Pitocin) infusion. Oxytocin can contribute to uteroplacental insufficiency, leading to late decelerations. This intervention aims to improve fetal oxygenation and prevent further stress on the fetus. Immediate cesarean birth is not the first-line action unless other interventions fail. Notifying the anesthesiologist about disconnecting the epidural infusion is not the priority in this situation. Applying an internal fetal monitoring device is invasive and not the immediate step needed when late decelerations are present.

4. The nurse is performing a physical assessment of a male client who has chronic renal failure. Which assessment finding is most important for the nurse to report to the healthcare provider?

• A. Client reports difficulty breathing
• B. Client reports shortness of breath when lying flat
• C. Client reports swelling in the feet and ankles
• D. Client reports a metallic taste in the mouth

Correct answer: A

Rationale: In a client with chronic renal failure, difficulty breathing is the most critical finding to report. This symptom may indicate fluid overload or pulmonary edema, which can be life-threatening. Shortness of breath when lying flat (orthopnea) is also concerning but less urgent than difficulty breathing. Swelling in the feet and ankles (edema) is a common finding in renal failure but may not be as immediately critical as difficulty breathing. A metallic taste in the mouth is associated with uremia, a common complication of chronic renal failure, but it is not as urgent as respiratory distress.

5. A postoperative client returns to the nursing unit following a ureter lithotomy via a flank incision. Which potential nursing problem has the highest priority when planning nursing care for this client?

• A. Ineffective airway clearance
• B. Altered nutrition less than body requirements
• C. Fluid volume excess
• D. Activity intolerance

Correct answer: A

Rationale: The correct answer is 'Ineffective airway clearance.' Following a ureter lithotomy via a flank incision, the highest priority nursing problem is ensuring the client's airway remains clear. This is crucial for effective breathing and oxygenation. Altered nutrition, fluid volume excess, and activity intolerance are important to address but are of lower priority compared to maintaining a clear airway postoperatively.

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