Nursing Elites

1. A client who is 2 hours postpartum reports heavy bleeding and passing large clots. What is the nurse's priority action?

• A. Perform fundal massage
• B. Administer oxytocin IV
• C. Check vital signs
• D. Encourage the client to void

Correct answer: A

Rationale: The correct answer is A: Perform fundal massage. Fundal massage promotes uterine contractions, which is the initial action to reduce postpartum hemorrhage caused by uterine atony. Checking vital signs (choice C) is important but not the priority when active bleeding is present. Administering oxytocin IV (choice B) may be needed but is not the priority action. Encouraging the client to void (choice D) does not address the underlying issue of postpartum hemorrhage and should not be the priority.

2. A nurse is assessing a client with pneumonia. Which of the following findings should the nurse expect?

• A. Bradycardia
• B. Increased respiratory rate
• C. Decreased temperature
• D. Elevated blood pressure

Correct answer: B

Rationale: The correct answer is B: Increased respiratory rate. In pneumonia, the body tries to compensate for the reduced ability to oxygenate the blood by increasing the respiratory rate. This helps to improve oxygen exchange. Bradycardia (Choice A) is not typically associated with pneumonia, as an increased heart rate is more common due to the stress on the body. Decreased temperature (Choice C) is not a typical finding in pneumonia, as infections usually cause a fever. Elevated blood pressure (Choice D) is not a common finding in pneumonia unless there are complications such as sepsis.

3. A nurse is teaching a client who has hypertension about dietary modifications to help control blood pressure. Which of the following food choices should the nurse recommend as the best choice for the client to include in their diet?

• A. 1 packet of reconstituted dry onion soup
• B. 3 oz of lean cured ham
• C. 3 oz of chicken breast
• D. 1/2 cup of canned baked beans

Correct answer: C

Rationale: A low sodium diet is recommended for a client who has hypertension. Therefore, the nurse should recommend 3 oz of chicken breast as the best choice for the client's diet because it contains 30 – 90 mg of sodium. Choice A, 1 packet of reconstituted dry onion soup, and Choice B, 3 oz of lean cured ham, are high in sodium content, which is not suitable for a client with hypertension. Choice D, 1/2 cup of canned baked beans, is also high in sodium, making it a less suitable choice compared to 3 oz of chicken breast.

4. A client is being educated by a nurse on how to use a PCA pump postoperatively. Which statement by the client indicates understanding?

• A. I should wait until the pain is severe before using the PCA pump.
• B. My family can press the button for me while I’m asleep.
• C. I will press the button when I start to feel pain.
• D. I will only press the button once per hour.

Correct answer: C

Rationale: The correct answer is C. This statement indicates understanding because the client recognizes that they should use the PCA pump when they start to feel pain. Waiting for the pain to become severe is not recommended as it may lead to inadequate pain control. Option B is incorrect because only the client should control the PCA pump to ensure safety and appropriate dosing. Option D is also incorrect as there is no set limit on how often the button can be pressed, as it should be used as needed when pain is felt.

5. A nurse is teaching about foot care to a client who has diabetes mellitus (DM). What statement indicates understanding?

• A. I should wear my slippers whenever I am out of bed
• B. I can walk barefoot at home
• C. I should apply lotion between my toes
• D. I can soak my feet in warm water

Correct answer: A

Rationale: The correct answer is A. Wearing slippers or shoes when out of bed is crucial for clients with diabetes as it protects the feet from injury. Walking barefoot, as mentioned in option B, can increase the risk of cuts, sores, and infections in diabetic patients. Applying lotion between the toes, as stated in option C, can lead to maceration and increase the risk of fungal infections. Similarly, soaking feet in warm water, as mentioned in option D, can cause skin breakdown and should be avoided by diabetic patients.

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