Nursing Elites

1. Which entry in the client record best reflects significant data on a male client who is admitted with complaints of chest pain?

• A. Nurse will check client q1h for the presence of chest pain
• B. Client has a nervous, tense personality and is likely to overreact
• C. Client states he will notify the nurse if chest pain returns
• D. Client understands how to use the call button and the telephone

Correct answer: C

Rationale: The correct answer is C because documenting the client's statement about notifying the nurse if chest pain returns provides direct, relevant information about their condition. This entry indicates the client's awareness of their symptoms and their willingness to seek assistance, which is crucial in managing chest pain. Choice A is incorrect because it focuses on the nurse's actions rather than the client's condition. Choice B is irrelevant as it discusses the client's personality rather than their current health issue. Choice D, though related to communication, does not directly address the client's chest pain complaint.

2. 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.

3. While a patient is receiving beta-1b interferon every other day for multiple sclerosis, which serum laboratory test findings should the nurse monitor to assess for possible bone marrow suppression caused by the medication? (Select all that apply)

• A. Platelet count
• B. White blood cell count (WBC)
• C. Sodium and potassium
• D. Red blood cell count (RBC)

Correct answer: A

Rationale: Beta-1b interferon can lead to bone marrow suppression, impacting blood cell production. Therefore, monitoring the platelet count, white blood cell count (WBC), and red blood cell count (RBC) is essential. Platelet count is a direct indicator of bone marrow function and can show early signs of bone marrow suppression. While sodium, potassium, and albumin/protein levels are important for overall health assessment, they are not directly associated with bone marrow suppression caused by the medication.

4. A female client on the mental health unit frequently asks the nurse when she can be discharged. Then, becoming more anxious, she begins to pace the hallway. What intervention should the nurse implement first?

• A. Review the current treatment plan with the client
• B. Inform the healthcare provider about the client’s behaviors
• C. Determine if the client has PRN medication for anxiety
• D. Explore the client’s reasons for wanting to be discharged

Correct answer: D

Rationale: Exploring the client’s reasons for wanting to be discharged should be the first intervention as it helps to address underlying anxieties and concerns. By understanding the client's motivations, the nurse can provide appropriate support and interventions. It can also reduce distress and improve the therapeutic relationship. Reviewing the treatment plan (Choice A) may be important but addressing the immediate distress takes precedence. Informing the healthcare provider (Choice B) can be considered later if necessary. Determining if the client has PRN medication (Choice C) is relevant, but exploring the underlying reasons for the desire to be discharged is more beneficial in this situation.

5. A client is admitted to the labor and delivery unit in early labor, and the nurse assesses the status of her contractions. The frequency of contractions is most accurately evaluated by counting the minutes and seconds in which manner?

• A. From the peak of one contraction to the peak of the next contraction
• B. From the beginning of one contraction to the end of that contraction
• C. From the beginning of one contraction to the beginning of the next contraction
• D. From the end of one contraction to the beginning of the next contraction

Correct answer: C

Rationale: The frequency of contractions is measured from the beginning of one contraction to the beginning of the next contraction. This timing is crucial in determining the progress of labor. Choice A, measuring from peak to peak, is incorrect as it assesses the duration between the highest points of contractions, which is not how frequency is calculated. Choice B, measuring from the beginning to the end of one contraction, is incorrect as it does not consider the start of the next contraction. Choice D, measuring from the end of one contraction to the beginning of the next contraction, is incorrect as it misses the initial onset of the following contraction.

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