Nursing Elites

1. A 6-year-old with heart failure (HF) gained 2 pounds in the last 24 hours. Which intervention is more important for the nurse to implement?

• A. Graph the daily weight for the past week.
• B. Decrease IV flow rate.
• C. Assess bilateral lung sounds.
• D. Restrict intake of oral fluids.

Correct answer: C

Rationale: Assessing bilateral lung sounds is crucial in this scenario as it can provide essential information about potential fluid accumulation in the lungs, indicating worsening heart failure. This assessment can guide immediate interventions to prevent further deterioration in the patient's condition.

2. Client teaching is an important part of the maternity nurse's role. Which factor has the greatest influence on successful teaching of the gravid client?

• A. The client's readiness to learn.
• B. The client's educational background.
• C. The order in which the information is presented.
• D. The extent to which the pregnancy was planned.

Correct answer: A

Rationale: The client's readiness to learn is the most critical factor influencing successful teaching of the gravid client. When a client is receptive and motivated to learn, they are more likely to engage with the information provided, leading to better understanding and retention.

3. A woman who gave birth 48 hours ago is bottle-feeding her infant. During assessment, the nurse determines that both breasts are swollen, warm, and tender upon palpation. What action should the LPN/LVN take?

• A. Apply cold compresses to both breasts for comfort.
• B. Instruct the client to run warm water on her breasts.
• C. Wear a loose-fitting bra to prevent nipple irritation.
• D. Express small amounts of milk to relieve pressure.

Correct answer: A

Rationale: After childbirth, engorgement of the breasts can occur, leading to swelling and discomfort. Applying cold compresses helps reduce swelling and provides comfort for engorged breasts. This action can also help with pain relief and promote milk flow regulation. Instructing the client to run warm water on her breasts (Choice B) is incorrect as warm water can increase blood flow and exacerbate swelling. Wearing a loose-fitting bra (Choice C) may provide some comfort, but it does not address the swelling effectively. Expressing small amounts of milk (Choice D) may provide temporary relief but does not address the underlying issue of engorgement.

4. The healthcare provider is preparing to give an enema to a laboring client. Which client requires the most caution when carrying out this procedure?

• A. A gravida 6, para 5 who is 38 years of age and in early labor.
• B. A 37-week primigravida who presents at 100% effacement, 3 cm cervical dilation, and a -1 station.
• C. A gravida 2, para 1 who is at 1 cm cervical dilation and a 0 station admitted for induction of labor due to postdates.
• D. A 40-week primigravida who is at 6 cm cervical dilation and the presenting part is not engaged.

Correct answer: D

Rationale: The client at 40 weeks of gestation with a 6 cm cervical dilation and a presenting part that is not engaged requires the most caution during an enema procedure. An unengaged presenting part increases the risk of cord prolapse, which can be a serious complication during the procedure. This situation demands careful attention to prevent potential complications and ensure the safety of the client and fetus. Choice A is incorrect as being in early labor does not pose the same level of risk as an unengaged presenting part. Choice B describes a client at 37 weeks with signs of early labor but does not indicate the same level of risk as an unengaged presenting part. Choice C involves a client at 1 cm cervical dilation and a 0 station with no mention of an unengaged presenting part, making it a less critical situation compared to an unengaged presentation, as in Choice D.

5. A 28-year-old client in active labor complains of cramps in her leg. What intervention should be implemented?

• A. Massage the calf and foot.
• B. Extend the leg and dorsiflex the foot.
• C. Lower the leg off the side of the bed.
• D. Elevate the leg above the heart.

Correct answer: B

Rationale: During active labor, if a client complains of leg cramps, extending the leg and dorsiflexing the foot can help relieve the muscle cramps by stretching the affected muscles. This intervention promotes circulation and can alleviate discomfort associated with leg cramps.

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