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 client with COPD expresses concerns about leaving the house due to continuous oxygen use. What is an appropriate response by the nurse?

• A. There are portable oxygen delivery systems that you can take with you.
• B. When you go out, you can remove the oxygen and then reapply it when you get home.
• C. You probably will not be able to go out as much as you used to.
• D. Home health services will come to see you so you will not need to get out.

Correct answer: A

Rationale: For a client with COPD concerned about leaving the house while on continuous oxygen, the nurse should provide reassurance by mentioning the availability of portable oxygen delivery systems. These systems allow the client to maintain their oxygen therapy while being mobile, enabling them to go out and engage in activities outside the home. This response promotes independence and quality of life for the client, addressing their immediate concerns and offering a practical solution to their perceived limitation.

3. A client with vision loss is under the care of a nurse. Which of the following actions should the nurse AVOID?

• A. Keep objects in the client's room in the same place
• B. Ensure there is high-wattage lighting in the client's room
• C. Approach the client from the side
• D. Allow extra time for the client to perform tasks

Correct answer: C

Rationale: Approaching a client with vision loss from the side can startle them and may lead to accidents or discomfort. It is important to approach them from the front so they are aware of your presence. Keeping objects in the same place aids in familiarity and reduces the risk of falls. High-wattage lighting enhances visibility for the client. Allowing extra time for tasks accommodates the client's potential slower pace and ensures they can perform tasks safely.

4. What is the appropriate needle gauge for intradermal injection?

• A. 20G
• B. 22G
• C. 25G
• D. 26G

Correct answer: D

Rationale: Intradermal injections require a very fine needle to be used to deliver the medication into the dermis layer of the skin. A 26G needle is typically used for intradermal injections as it is thin enough to penetrate the skin's surface and deposit the medication accurately.

5. A client is experiencing preterm contractions and dehydration. Which of the following statements should the nurse make?

• A. Dehydration is treated with calcium supplements.
• B. Dehydration can increase the risk of preterm labor.
• C. Dehydration is associated with gastroesophageal reflux.
• D. Dehydration is caused by decreased hemoglobin and hematocrit.

Correct answer: B

Rationale: Dehydration can lead to an imbalance in electrolytes and cause uterine irritability, potentially leading to preterm contractions. It is essential for the nurse to educate the client on the importance of adequate hydration to reduce the risk of preterm labor. The statement 'Dehydration can increase the risk of preterm labor' directly addresses the client's condition and provides relevant information for their understanding and management of the situation.

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