Nursing Elites

1. A client is admitted to the floor with vomiting and diarrhea for three days. She is receiving IV fluids at 200cc/hr via pump. A priority action for the nurse would be:

• A. Obtaining Intake and Output.
• B. Frequent lung assessments.
• C. Vital signs every shift.
• D. Monitoring the IV site for infiltration.

Correct answer: D

Rationale: In this scenario, the correct priority action for the nurse would be monitoring the IV site for infiltration. The client is receiving IV fluids at a rapid rate, making it crucial to ensure that the IV site is intact and not causing any complications like infiltration, which can lead to tissue damage. While frequent lung assessments are important for detecting signs of fluid overload, in this case, ensuring the IV site's integrity takes precedence. Obtaining Intake and Output is relevant but not the priority over monitoring the IV site. Vital signs are essential, but given the situation, the immediate concern is the IV site's condition to prevent complications.

2. Jane Love, a 35-year-old gravida III para II at 23 weeks gestation, is seen in the Emergency Department with painless, bright red vaginal bleeding. Jane reports that she has been feeling tired and has noticed ankle swelling in the evening. Laboratory tests reveal a hemoglobin level of 11.5 g/dL. After evaluating the situation, the nurse determines that Jane is at risk for placenta previa, based on which of the following data?

• A. anemia
• B. edema
• C. painless vaginal bleeding
• D. fatigue

Correct answer: C

Rationale: Placenta previa is a disorder where the placenta implants in the lower uterine segment, causing painless bleeding in the third trimester of pregnancy. The bleeding results from tearing of the placental villi from the uterine wall as the lower uterine segment contracts and dilates. It can be slight or profuse and can include bright red, painless bleeding. While anemia (choice A) may be a consequence of chronic bleeding from placenta previa, it is not a direct indicator. Edema (choice B) and fatigue (choice D) are nonspecific symptoms that can occur in pregnancy but are not specific to placenta previa.

3. A client is experiencing chest pain. Which statement made by the client indicates angina rather than a myocardial infarction?

• A. "I became dizzy when I stood up."?
• B. "I was nauseated and began vomiting."?
• C. "The pain started in my chest and stopped after I sat down."?
• D. "The pain began with a migraine and progressed to numbness in my left arm."?

Correct answer: B

Rationale: The correct answer is: '"The pain started in my chest and stopped after I sat down."? This statement suggests angina rather than a myocardial infarction because angina is typically triggered by exertion or stress and relieved by rest. Nausea and vomiting (Choice B) are more commonly associated with a myocardial infarction. Choices A and D are not typical symptoms of either angina or myocardial infarction.

4. A client with sickle cell disease is worried about passing the disease on to children. Which of the following statements by the PN is most appropriate for this client?

• A. "You should discuss the inheritance risk with your physician."?
• B. "Sickle cell disease is genetically based and might be passed on to children."?
• C. "Sickle cell disease is genetically based and is not passed on to children."?
• D. "Sickle cell disease is caused by an infection and cannot be passed on to children."?

Correct answer: B

Rationale: A client with sickle cell disease has a genetic condition that can be passed on to their offspring. The most appropriate statement for the PN to provide is to acknowledge this fact and inform the client that sickle cell disease is genetically based and might be passed on to children. This empowers the client with accurate information. Choice A has been refined to emphasize discussing the inheritance risk, making it a better option than the vague original choice. Choices C and D provide incorrect information. Sickle cell disease is indeed genetically based and can be inherited.

5. A female client complains to the nurse at the health department that she has fatigue, shortness of breath, and lightheadedness. Her history reveals no significant medical problems. She states that she is always on a fad diet without any vitamin supplements. Which tests should the nurse expect the client to have first?

• A. peptic ulcer studies
• B. complete blood count, including hematocrit and hemoglobin
• C. genetic testing
• D. hemoglobin electrophoresis

Correct answer: B

Rationale: The correct answer is to perform a complete blood count, including hematocrit and hemoglobin, as the initial tests to assess the client's symptoms related to fatigue, shortness of breath, and lightheadedness. These symptoms can be indicative of anemia, which can be caused by nutritional deficiencies due to fad dieting without vitamin supplements. Peptic ulcer studies, genetic testing, and hemoglobin electrophoresis are not the most appropriate initial tests for the client's presenting symptoms and history. Peptic ulcer studies are not relevant to the client's symptoms. Genetic testing is not indicated based on the client's presentation and history. Hemoglobin electrophoresis is used to diagnose specific types of anemia and is not the first-line test in this scenario. Further testing decisions should be based on the results of the initial tests, the client's history, and other relevant factors.

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