Nursing Elites

1. A client presents to the labor and delivery unit with a report of leaking fluid that is greenish-brown vaginal discharge. Which action should the nurse take first?

• A. Notify the healthcare provider immediately
• B. Begin continuous fetal monitoring
• C. Check the amniotic fluid pH
• D. Assess maternal vital signs

Correct answer: B

Rationale: Greenish-brown discharge likely indicates meconium in the amniotic fluid, which poses a risk to the fetus. Continuous fetal monitoring should be initiated immediately to assess for signs of fetal distress. Meconium-stained amniotic fluid can lead to meconium aspiration syndrome in the newborn, so timely monitoring is crucial. Checking the amniotic fluid pH can help confirm the presence of meconium but is not the priority over fetal monitoring. Assessing maternal vital signs is important but secondary to monitoring the fetal well-being in this urgent situation. Notifying the healthcare provider can follow once the immediate fetal assessment is underway.

2. A combination multi-drug cocktail is being considered for an asymptomatic HIV-infected client with a CD4 cell count of 500. Which nursing assessment of the client is most crucial in determining whether therapy should be initiated?

• A. Presence of viral symptoms
• B. Engages in high-risk behaviors
• C. Willingness to comply with complex drug schedules
• D. History of opportunistic infections

Correct answer: C

Rationale: The most crucial nursing assessment in determining whether therapy should be initiated for an asymptomatic HIV-infected client with a CD4 cell count of 500 is the client's willingness to comply with complex drug schedules. Adherence to antiretroviral therapy is essential for its effectiveness. Assessing the client's willingness and ability to comply with the complex medication regimen is crucial to ensure successful treatment and prevent drug resistance. Choices A, B, and D, although important in the overall care of the client, are not as crucial as assessing the client's willingness to adhere to the prescribed drug regimen.

3. A nurse is planning discharge teaching for a client with congestive heart failure (CHF). Which dietary instruction should the nurse provide?

• A. Limit sodium intake to reduce fluid retention
• B. Consume high-protein foods to strengthen the heart
• C. Increase potassium intake to manage blood pressure
• D. Increase fluid intake to promote hydration

Correct answer: A

Rationale: The correct answer is A: Limit sodium intake to reduce fluid retention. Limiting sodium intake is crucial for managing congestive heart failure (CHF) as it helps reduce fluid retention. Excess fluid retention can worsen CHF by increasing the workload on the heart. Choice B is incorrect because while protein is essential for overall health, it is not directly related to managing CHF. Choice C is incorrect because potassium, although important, is not the primary focus in managing CHF. Choice D is incorrect because increasing fluid intake can exacerbate fluid retention in CHF patients.

4. A client with cirrhosis is receiving spironolactone. What electrolyte level should the nurse monitor closely?

• A. Monitor potassium levels.
• B. Monitor sodium levels.
• C. Monitor calcium levels.
• D. Monitor magnesium levels.

Correct answer: A

Rationale: The correct answer is to monitor potassium levels. Spironolactone is a potassium-sparing diuretic, which means it helps the body retain potassium and excrete sodium. Monitoring potassium levels closely is essential because spironolactone can cause hyperkalemia (high potassium levels). Sodium levels are not typically affected by spironolactone. Calcium and magnesium levels are also not directly impacted by spironolactone, making choices B, C, and D incorrect.

5. A client has a nasogastric tube after colon surgery. Which one of these tasks can be safely delegated to an unlicensed assistive personnel (UAP)?

• A. To observe the type and amount of nasogastric tube drainage
• B. Monitor the client for nausea or other complications
• C. Irrigate the nasogastric tube with the ordered irrigation solution
• D. Perform nostril and mouth care

Correct answer: D

Rationale: Performing nostril and mouth care is a non-invasive task that can be safely delegated to an unlicensed assistive personnel (UAP). Observing the type and amount of nasogastric tube drainage requires assessment skills and understanding of potential complications, making it more appropriate for a licensed healthcare professional. Monitoring the client for nausea or other complications involves interpreting client responses and identifying adverse reactions, which also requires a licensed healthcare professional. Irrigating the nasogastric tube with the ordered solution involves a procedure that can impact the client's condition and should be performed by a licensed healthcare professional to prevent complications.

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