Nursing Elites

1. What nursing intervention is particularly indicated for the second stage of labor?

• A. Providing pain medication to increase the client’s tolerance of labor
• B. Assessing the fetal heart rate and pattern for signs of fetal distress
• C. Monitoring effects of oxytocin administration to help achieve cervical dilation
• D. Assisting the client to push effectively so that the expulsion of the fetus can be achieved

Correct answer: D

Rationale: During the second stage of labor, assisting the client to push effectively is crucial for the delivery of the fetus. This action helps to facilitate the expulsion of the fetus from the uterus. Providing pain medication (Choice A) is not typically done during the second stage of labor as the focus shifts to pushing and delivery. Assessing the fetal heart rate (Choice B) is important but is more relevant throughout labor, not specifically for the second stage. Monitoring the effects of oxytocin administration (Choice C) is more associated with the first stage of labor to help with uterine contractions and cervical dilation.

2. Two weeks following a Billroth II (gastrojejunostomy), a client develops nausea, diarrhea, and diaphoresis after every meal. When the nurse develops a teaching plan for this client, which expected outcome statement is the most relevant?

• A. Describes a schedule for antacid use in combination with other prescribed medications
• B. Selects a pattern of small meals interspersed with fluid intake
• C. Commits to engaging in a variety of stress reduction techniques
• D. Expresses a commitment to decrease nicotine intake

Correct answer: B

Rationale: The symptoms described are indicative of dumping syndrome, a common complication following a Billroth II procedure. Dumping syndrome presents with symptoms such as nausea, diarrhea, and diaphoresis after meals. To manage these symptoms effectively, the client should opt for small, frequent meals and avoid consuming fluids along with meals. Choice A is inaccurate because antacid use does not directly address the symptoms of dumping syndrome. Choice C is irrelevant as stress reduction techniques are not the primary intervention for dumping syndrome. Choice D is unrelated to the symptoms experienced by the client, making it an inappropriate choice.

3. The client who is to avoid any weight-bearing on the left leg is using a 3-point crutch gait for ambulation. What is the best action for the nurse to initiate?

• A. Encourage continued use of the 3-point crutch gait by the client
• B. Encourage the client to use a wheelchair for mobility
• C. Instruct the client in the use of a 4-point crutch gait
• D. Instruct the client in the use of a 2-point crutch gait

Correct answer: C

Rationale: In this scenario, the client needs to avoid weight-bearing on the left leg. A 4-point crutch gait involves using both crutches and both legs, making it more appropriate for weight-bearing restrictions. Encouraging the use of a 3-point gait (choice A) would not provide adequate support for the client's condition. While using a wheelchair (choice B) could be an option, instructing the client in a 4-point crutch gait would promote mobility while adhering to weight-bearing restrictions. A 2-point crutch gait (choice D) involves using both crutches and one leg, which is not suitable for avoiding weight-bearing on the left leg.

4. An adolescent male client is admitted to the hospital. Based on Erikson’s theory of psychosocial development, which nursing intervention best assists this adolescent’s adjustment to his hospital stay?

• A. Invite him to participate in the evening group activity
• B. Schedule frequent private phone calls to his parents
• C. Provide access to a variety of video games in his room
• D. Encourage him to learn his way around the hospital

Correct answer: A

Rationale: Inviting the adolescent to participate in group activities aligns with Erikson's theory of psychosocial development, specifically the stage of developing social relationships. By engaging in group activities, the adolescent can interact with peers, fostering social skills and aiding in adjustment to the hospital environment. Choice B is incorrect as excessive reliance on phone calls to parents may hinder the adolescent's autonomy and independence, which are crucial aspects of Erikson's theory for this age group. Choice C, providing access to video games, while potentially offering entertainment, does not directly address the need for social interaction and relationship-building. Choice D, encouraging the adolescent to learn his way around the hospital, is important for familiarity but may not directly address the need for social interaction and adjustment in the hospital setting.

5. A client who is scheduled to have surgery in two hours tells the nurse, 'My doctor was here and used a lot of big words about the surgery, then asked me to sign a paper.' What action should the nurse take?

• A. Reassure the client that pre-surgery anxiety is a normal experience
• B. Explain the surgery in clear terms that the client can understand
• C. Call the surgeon back to clarify the information with the client
• D. Redirect the client’s thoughts by teaching relaxation techniques

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to explain the surgery to the client in clear terms that they can understand. This will help alleviate the client's anxiety and ensure they are well-informed about the procedure they are about to undergo. Choice A is incorrect because while reassurance is important, it does not address the client's specific concern about understanding the surgery. Choice C is not the initial step; the nurse should first attempt to clarify the information themselves. Choice D is not the priority when the client is seeking clarification about the surgery.

Similar Questions