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. For a rectal examination, the patient can be directed to assume which of the following positions?

• A. Genupectoral
• B. Sims
• C. Horizontal recumbent
• D. All of the above

Correct answer: B

Rationale: The correct position for a rectal examination is the Sims position, where the patient lies on their left side with the upper knee flexed. This position allows for easy access and visualization of the rectal area for examination.

3. A patient requires augmentation of labor. Which of the following conditions should the nurse recognize as a contraindication to the use of oxytocin?

• A. Diabetes mellitus
• B. Shoulder presentation
• C. Postterm with oligohydramnios
• D. Chorioamnionitis

Correct answer: C

Rationale: Postterm pregnancy with oligohydramnios is a contraindication for the use of oxytocin due to the increased risk of uterine hyperstimulation and fetal distress. Oxytocin can further stress the fetus in this scenario, potentially leading to adverse outcomes. Therefore, it is crucial for the nurse to recognize this contraindication to ensure the safety of both the mother and the baby during labor.

4. Which of the following is included in Orem’s theory?

• A. Maintenance of a sufficient intake of air
• B. Self-perception
• C. Love and belonging
• D. Physiological needs

Correct answer: A

Rationale: Orem's theory, also known as the Self-Care Deficit Nursing Theory, focuses on individuals' ability to perform self-care to maintain health and well-being. One specific component of this theory is the maintenance of a sufficient intake of air, which is crucial for sustaining life and overall health. Option A is the correct choice as it directly relates to meeting physiological needs, such as the intake of air, to support optimal functioning and health. Choices B, C, and D are incorrect as they do not specifically align with Orem's emphasis on self-care and meeting physiological requirements.

5. A client has experienced a right-hemispheric stroke. Which of the following is not an expected finding?

• A. Impulse control difficulty
• B. Left hemiplegia
• C. Loss of depth perception
• D. Aphasia

Correct answer: D

Rationale: In a right-hemispheric stroke, the expected findings include left-sided hemiplegia (Choice B), loss of depth perception (Choice C), and impulse control difficulty (Choice A). Aphasia (Choice D) is typically associated with left-hemispheric strokes. Therefore, aphasia is not an expected finding in a client who has experienced a right-hemispheric stroke.

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