Nursing Elites

1. When assessing a client in the Emergency Department whose membranes have ruptured, the nurse notes that the fluid is a greenish color. What is the cause of this greenish coloration?

• A. blood
• B. meconium
• C. hydramnios
• D. caput

Correct answer: B

Rationale: The correct answer is B: meconium. Greenish amniotic fluid passed when the fetus is in a cephalic (head) presentation might indicate fetal distress. A fetus in the breech presentation passes meconium due to compression on the intestinal tract. Choice A, blood, is incorrect as blood in the amniotic fluid would present as a different color. Choice C, hydramnios, refers to an excess of amniotic fluid and would not cause the greenish coloration. Choice D, caput, is swelling of a newborn's scalp and is not related to the color of the amniotic fluid.

2. A 20-year-old obese female client is preparing to have gastric bypass surgery for weight loss. She says to the nurse, 'I need this surgery because nothing else I have done has helped me to lose weight.' Which response by the nurse is most appropriate?

• A. "If you eat less, you can save some money."?
• B. "Exercise is a healthier way to lose weight."?
• C. "You should try the Atkins diet first."?
• D. "I respect your decision to choose surgery."?

Correct answer: D

Rationale: The most appropriate response by the nurse is to show respect and empathy towards the client's decision. Choosing surgery for weight loss is a significant decision, and acknowledging and respecting this choice is crucial in providing patient-centered care. Option D is the correct answer as it validates the client's decision and shows support. Options A, B, and C are all inappropriate as they do not address the client's feelings, lack empathy, and can be considered insensitive and unprofessional.

3. A nurse has been ordered to set up Buck's traction on a patient's lower extremity due to a femur fracture. Which of the following applies to Buck's traction?

• A. A weight greater than 10 lbs. should be used.
• B. The line of pull is upward at an angle.
• C. The line of pull is straight
• D. A weight greater than 20 lbs. should be used.

Correct answer: C

Rationale: The correct answer is that the line of pull is straight for Buck's traction. This type of traction is applied to maintain alignment and immobilization of fractures, typically involving the lower extremities. A straight line of pull helps to provide the necessary countertraction to keep the fractured bone in proper alignment. Choices A and D are incorrect because Buck's traction commonly uses a weight range between 5-10 lbs, and using a weight greater than 10 or 20 lbs would not be appropriate or safe. Choice B is incorrect as well since the line of pull for Buck's traction is straight, not upward at an angle.

4. Why must the nurse be careful not to cut through or disrupt any tears, holes, bloodstains, or dirt present on the clothing of a client who has experienced trauma?

• A. The clothing may be potential evidence with legal implications.
• B. Such care facilitates the preservation of potential evidence.
• C. The clothing of a trauma victim can be used for further investigation.
• D. Such care maintains the integrity of the clothing for forensic analysis.

Correct answer: C

Rationale: In cases of trauma, the clothing of a client can hold crucial evidence that may have legal implications. It is essential for the nurse to avoid cutting through or disrupting any tears, holes, bloodstains, or dirt present on the clothing to preserve this potential evidence. The correct answer highlights the legal importance of preserving the clothing for potential legal implications. Choice B is related but does not emphasize the legal aspect explicitly. Choice C is vague in mentioning further investigation without specifying the legal significance. Choice D focuses more on forensic analysis rather than the legal implications of preserving the clothing.

5. The nurse overhears two nursing students talking about a client in the cafeteria. What should the nurse do first?

• A. Report the incident to the nursing supervisor.
• B. Write up a variance report about the incident.
• C. Instruct the students that this is a violation of HIPAA.
• D. Notify the students' faculty regarding the violation.

Correct answer: C

Rationale: The correct answer is to instruct the students that discussing a client in a public area like the cafeteria violates HIPAA regulations. This is important to educate the students about patient confidentiality and the consequences of breaching it. Reporting to the nursing supervisor or faculty should come after addressing the students directly. Writing up a variance report is not the immediate action needed in this situation, as educating the students about their mistake should be the priority. It is essential to address the issue at the source by educating the students first rather than escalating the matter to supervisors or faculty immediately.

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