Nursing Elites

1. A client is admitted to the labor and delivery unit in early labor, and the nurse assesses the status of her contractions. The frequency of contractions is most accurately evaluated by counting the minutes and seconds in which manner?

• A. From the peak of one contraction to the peak of the next contraction
• B. From the beginning of one contraction to the end of that contraction
• C. From the beginning of one contraction to the beginning of the next contraction
• D. From the end of one contraction to the beginning of the next contraction

Correct answer: C

Rationale: The frequency of contractions is measured from the beginning of one contraction to the beginning of the next contraction. This timing is crucial in determining the progress of labor. Choice A, measuring from peak to peak, is incorrect as it assesses the duration between the highest points of contractions, which is not how frequency is calculated. Choice B, measuring from the beginning to the end of one contraction, is incorrect as it does not consider the start of the next contraction. Choice D, measuring from the end of one contraction to the beginning of the next contraction, is incorrect as it misses the initial onset of the following contraction.

2. The nurse discontinues a continuous IV heparin infusion for a male client on strict bedrest and is now preparing to administer the client's first dose of enoxaparin. Prior to giving this subcutaneous injection, which assessment finding requires additional intervention by the nurse?

• A. Current lab report indicates an Aptt at 1.5 times the client's control
• B. The client states that his right calf is aching and wants pain medication
• C. The spouse is assisting the client who is shaving with an electric razor
• D. Several bruised areas are noted on the client's upper extremities bilaterally

Correct answer: D

Rationale: The correct answer is D. Bruised areas on the client's upper extremities bilaterally indicate an increased risk of bleeding, which requires careful assessment before administering enoxaparin. Bruising suggests potential issues with clotting and hemostasis, making it crucial for the nurse to further evaluate the client's bleeding risk. Choices A, B, and C do not directly relate to the assessment of bleeding risk associated with enoxaparin administration and are therefore incorrect. Choice A provides information about the client's Aptt, which is not directly relevant to assessing bleeding risk for enoxaparin. Choice B addresses pain management, and Choice C involves the client's daily activities with no direct link to the bleeding risk assessment.

3. An older client comes to the clinic with a family member. When the nurse attempts to take the client’s health history, the client does not respond to questions clearly. What action should the nurse implement first?

• A. Assess the surroundings for noise and distractions
• B. Provide a printed health history form
• C. Defer the health history until the client is less anxious
• D. Ask the family member to answer the questions

Correct answer: A

Rationale: The correct action for the nurse to implement first is to assess the surroundings for noise and distractions. This step is crucial as environmental factors can affect the client's ability to respond clearly. By minimizing noise and distractions, the nurse can create a more conducive environment for effective communication. Providing a printed form (Choice B) may help but addressing environmental factors should come first. Deferring the health history (Choice C) or asking the family member to answer the questions (Choice D) should not be the initial steps, as they do not directly address the issue of unclear communication with the client.

4. After the diagnosis and initial treatment of a 3-year-old with Cystic fibrosis, the nurse provides home care instructions to the mother. Which statement by the child's mother indicates that she understands home care treatment to promote pulmonary functions?

• A. Chest physiotherapy should be performed twice a day before a meal
• B. Energy should be conserved by scheduling minimally strenuous activities
• C. Administer a cough suppressant every 8 hours
• D. Maintain supplemental oxygen at 4 to 6 L/minute

Correct answer: A

Rationale: The correct answer is A. Chest physiotherapy is essential for maintaining pulmonary function in cystic fibrosis. It should be performed regularly, often twice daily, to clear mucus from the lungs. Choice B is incorrect because conserving energy does not directly promote pulmonary function. Choice C is incorrect as cough suppressants are not typically used to promote pulmonary function in cystic fibrosis. Choice D is incorrect as maintaining supplemental oxygen at 4 to 6 L/minute is not a standard home care treatment for promoting pulmonary functions in cystic fibrosis.

5. A male client approaches the nurse with an angry expression on his face and raises his voice, saying, “My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out.” The nurse recognizes that the client is using which defense mechanism?

• A. Denial
• B. Splitting
• C. Projection
• D. Rationalization

Correct answer: C

Rationale: The client is projecting his feelings of anger and frustration onto his roommate, attributing his own feelings to the other person. Projection is a defense mechanism where individuals attribute their thoughts, feelings, or motives onto another person. In this scenario, the client is displacing his anger onto his roommate, thereby using projection as a defense mechanism. Denial (choice A) is refusing to acknowledge an aspect of reality. Splitting (choice B) involves viewing people as all good or all bad. Rationalization (choice D) is creating logical explanations to justify unacceptable behavior.

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