Nursing Elites

1. After a client has a tubal ligation in the outpatient surgical clinic, what is the priority for the nurse to determine?

• A. The client's prior experiences with outpatient surgery
• B. The client's medical plan and the extent of coverage for outpatient surgery
• C. The client's plan for transportation and care at home
• D. The client's plan to spend the night at the surgical center

Correct answer: C

Rationale: The priority for the nurse is to ensure the client has a safe way to get home and adequate care after discharge. It is crucial to determine the client's transportation arrangements and availability of care at home to ensure a smooth transition postoperatively. Options A and B, though important, are not immediate priorities compared to the client's safety and well-being after the procedure. Option D is incorrect as spending the night at the surgical center is not typically part of the plan for outpatient surgery.

2. A client delivered a term male infant four hours ago. The infant was stillborn. Which room assignment would be most appropriate for this client?

• A. Request a private room on the GYN floor
• B. Assign her to a private room on the postpartum unit
• C. Discharge her home as soon as her condition is stable
• D. Room her with another client who experienced a pregnancy loss

Correct answer: A

Rationale: In this situation, the most appropriate room assignment for the client who delivered a stillborn infant would be to request a private room on the GYN floor. This client needs privacy to grieve, and having a private space allows for family members to offer support. Placing her in a GYN unit ensures that she is away from the maternity unit's sights and sounds, which could be painful reminders for her. Assigning her to a postpartum unit may cause distress due to the presence of other mothers and newborns. Discharging her home too early may not allow her sufficient time for emotional and physical recovery. Rooming her with another client who experienced a pregnancy loss may not provide the necessary privacy and space she needs for her emotional well-being.

3. A patient has been admitted to the hospital with an L4-5 HNP diagnosis. After 24 hours, the patient is able to ambulate with assistance and has reduced muscle spasms. Which of the following medications was the most beneficial in changing the patient's mobility status?

• A. Mivacron
• B. Atropine
• C. Bethanechol
• D. Flexeril

Correct answer: D

Rationale: The correct answer is Flexeril. Flexeril is a muscle relaxant commonly used to treat acute muscle pain and spasms. In this scenario, the patient experiencing reduced muscle spasms and improved mobility after taking Flexeril indicates its effectiveness. Choice A, Mivacron, is a neuromuscular blocking agent that is not typically used for muscle spasms or pain relief. Choice B, Atropine, is a medication used to treat certain types of nerve agent and pesticide poisonings, not muscle spasms. Choice C, Bethanechol, is a medication that stimulates bladder contractions and is not indicated for muscle spasms or mobility improvement.

4. A nurse is assessing an 18-year-old female who has recently suffered a TBI. The nurse notes a slower pulse and impaired respiration. The nurse should report these findings immediately to the physician due to the possibility the patient is experiencing which of the following conditions?

• A. Increased intracranial pressure
• B. Increased function of cranial nerve X
• C. Sympathetic response to activity
• D. Meningitis

Correct answer: A

Rationale: The nurse should report the slower pulse and impaired respiration to the physician immediately as they are indicative of increased intracranial pressure (ICP) following a traumatic brain injury (TBI). These signs suggest that there may be a rise in pressure within the skull, which can be a life-threatening condition requiring urgent intervention. Options B and C are unlikely in this scenario as they do not correlate with the symptoms presented. Meningitis (Option D) typically presents with different signs and symptoms, such as fever, headache, and neck stiffness, which are not described in the patient's case.

5. The nurse is assessing the newborn's respirations. Which of these findings would indicate a need for follow-up and further intervention?

• A. irregular respirations
• B. abdominal respirations
• C. shallow respirations
• D. 70 breaths per minute

Correct answer: D

Rationale: The ideal respiratory rate in a newborn is 30-60 breaths per minute. A respiratory rate of 70 breaths per minute indicates tachypnea and may require intervention. Therefore, a rate of 70 breaths per minute would necessitate follow-up and further intervention. Irregular, abdominal, and shallow respirations are common in newborns and may not necessarily indicate the need for immediate follow-up or intervention.

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