Nursing Elites

1. A charge nurse on an obstetrical unit is preparing the shift assignment. Which of the following clients should be assigned to an RN who has floated from a medical-surgical unit?

• A. A client who is at 32 weeks of gestation and has premature rupture of membranes
• B. A multigravida client who has preeclampsia and is receiving misoprostol for induction of labor
• C. A primigravida client who is 1 day postoperative following a Cesarean section and has a PCA pump
• D. A client who has gestational diabetes and is receiving biweekly nonstress tests

Correct answer: C

Rationale: A nurse who floated from a medical-surgical unit would be appropriate to care for a client who is 1 day postoperative following a Cesarean section and has a PCA pump. This client requires monitoring of the postoperative incision site, pain management through the PCA pump, and assessment for any signs of complications related to the surgery. Assigning this client to an RN with experience in postoperative care aligns with providing specialized and appropriate care. Choices A, B, and D involve conditions or procedures specific to obstetrics that would be better managed by a nurse with obstetrical experience, making them incorrect choices for the floated RN.

2. Select the stage of shock that is accurately paired with its characteristic.

• A. The initial stage of shock: Hyperventilation occurs and the blood pH rises.
• B. The compensatory stage of shock: Hypoxia occurs and lactic acid rises.
• C. The progressive stage of shock: Histamine is released; fluid and proteins leak into surrounding tissues and the blood thickens.
• D. The refractory stage of shock: Potassium ions leak out; sodium ions build up, and metabolic acidosis increases.

Correct answer: C

Rationale: The progressive stage of shock is accurately described as the stage where histamine is released, leading to fluid and proteins leaking into surrounding tissues and the blood thickening. In this stage, the body's compensatory mechanisms are overwhelmed, resulting in a cascade of events that worsen the shock state. Choice A is incorrect as hyperventilation and a rise in blood pH are more characteristic of the compensatory stage. Choice B is incorrect as hypoxia and a rise in lactic acid are more typical of the progressive stage. Choice D is incorrect as the described electrolyte imbalances and metabolic acidosis are more aligned with the refractory stage of shock.

3. Marlisa has been diagnosed with diabetes mellitus type 1. She asks Nurse Errol what this means. What is the best response by the nurse? Select the one that does not apply.

• A. Your beta cells should be able to secrete insulin, but cannot.
• B. The endocrine function of your pancreas is to secrete insulin.
• C. Without insulin, you will develop ketoacidosis (DKA).
• D. The exocrine function of your pancreas is to secrete Estrogen.

Correct answer: D

Rationale: Type 1 diabetes is characterized by the inability of the beta cells in the pancreas to secrete insulin. Choice A is correct because it highlights the role of beta cells. Choice B is accurate as the endocrine function of the pancreas includes insulin secretion. Choice C is true as without insulin, ketoacidosis can develop. Choice D is incorrect as the exocrine function of the pancreas involves secreting digestive enzymes, not estrogen.

4. Select all of the risk factors that are associated with deep vein thrombosis.

• A. The use of oral contraceptives
• B. Type B and O blood
• C. Rh negative blood
• D. Underweight

Correct answer: A

Rationale: The correct answer is A: "The use of oral contraceptives." Risk factors for deep vein thrombosis include factors such as immobility, surgery, cancer, obesity, smoking, and the use of oral contraceptives. Choices B, C, and D are incorrect because blood type and Rh factor do not play a role in the development of deep vein thrombosis, and being underweight is not typically considered a risk factor for this condition.

5. Low birth weight is defined as a newborn's weight of:

• A. 2500 grams or less at birth, regardless of gestational age.
• B. 1500 grams or less at birth, regardless of gestational age.
• C. 2500 grams or less at birth, according to gestational age.
• D. 1500 grams or less at birth, according to gestational age.

Correct answer: A

Rationale: Low birth weight is defined as 2500 grams or less at birth, regardless of gestational age. This means that any newborn weighing 2500 grams or less is considered to have a low birth weight, irrespective of how many weeks they were in the womb. Choices B, C, and D are incorrect because they specify a weight of 1500 grams or less, which is not the standard definition of low birth weight. The correct definition is 2500 grams or less, not influenced by gestational age.

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