Nursing Elites

1. A charge nurse is recommending postpartum client discharge following a local disaster. Which of the following should the nurse recommend for discharge?

• A. A 42-year-old client who has preeclampsia and a BP of 166/110 mm Hg
• B. A 15-year-old client who delivered via emergency cesarean birth 1 day ago
• C. A client who received 2 units of packed RBCs 6 hr ago for a postpartum hemorrhage
• D. A client who delivered precipitously 36 hr ago and has a second-degree perineal laceration

Correct answer: D

Rationale: The most appropriate client to recommend for discharge following a local disaster in the postpartum unit is the one who delivered precipitously 36 hours ago and has a second-degree perineal laceration. This client's condition is stable enough for discharge, and the timing and extent of the perineal laceration are within expectations for a safe discharge. Clients with conditions such as preeclampsia, recent emergency cesarean birth, or recent administration of packed RBCs for postpartum hemorrhage require further monitoring and care before being considered for discharge.

2. A healthcare professional is preparing to measure an infant's temperature. Which of the following actions should the healthcare professional take?

• A. Place the tip of the thermometer under the center of the infant's axilla
• B. Pull the pinna of the infant's ear forward before inserting the probe
• C. Insert the probe 3.8 cm (1.5in) into the infant's rectum
• D. Insert the thermometer in front of the infant's tongue

Correct answer: A

Rationale: When measuring an infant's temperature, the most appropriate and non-invasive method is to place the tip of the thermometer under the center of the infant's axilla (armpit). This method is safe, quick, and comfortable for the infant. Inserting the probe into the rectum is invasive and not recommended for routine temperature measurement in infants. Inserting the thermometer in front of the infant's tongue is not a reliable method for measuring temperature. Pulling the pinna of the ear forward is a technique used for adults, not infants.

3. After 1 week of hospitalization, Mr. Gray develops hypokalemia. Which of the following is the most significant symptom of his disorder?

• A. Lethargy
• B. Increased pulse rate and blood pressure
• C. Muscle weakness
• D. Muscle irritability

Correct answer: C

Rationale: Muscle weakness is a hallmark symptom of hypokalemia. Hypokalemia refers to low levels of potassium in the blood, which can affect muscle function. The decreased potassium levels can lead to muscle weakness, cramping, and even paralysis. These symptoms can impact various muscle groups in the body, making muscle weakness the most significant symptom to monitor and address in patients with hypokalemia.

4. Which of the following conditions in the client's history is a contraindication to the use of oral contraceptives?

• A. Hyperthyroidism.
• B. Thrombophlebitis.
• C. Diverticulosis.
• D. Hypocalcemia.

Correct answer: B

Rationale: Thrombophlebitis, which is inflammation of a vein with the formation of a clot, is a contraindication to the use of oral contraceptives due to an increased risk of thromboembolism. Clients with a history of thrombophlebitis or thromboembolic disorders should avoid oral contraceptives to prevent further complications like deep vein thrombosis or pulmonary embolism.

5. Which of the following principles of primary nursing has proven the most satisfying to the patient and nurse?

• A. Administer oxygen by Venturi mask at 24% as needed
• B. Allow a 1-hour rest period between activities
• C. Patients and nurses both respond well to primary nursing care units
• D. Studies have shown that patients and nurses both respond well to primary nursing care units

Correct answer: C

Rationale: Primary nursing care units have been proven to be highly satisfying for both patients and nurses. This model promotes a consistent and continuous relationship between a patient and a primary nurse, leading to improved communication, personalized care, and overall satisfaction for both parties involved.

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