Nursing Elites

1. A client who is 32-weeks pregnant is diagnosed with partial placenta previa. Which instruction should the nurse include in this client’s teaching plan?

• A. Wear a tight abdominal binder at all times
• B. Take a daily laxative to prevent constipation
• C. Refrain from sexual intercourse until your next appointment
• D. Restrict fluids to less than 1000 ml per day

Correct answer: C

Rationale: Refraining from sexual intercourse helps prevent complications with partial placenta previa.

2. One hour after delivery, the nurse is unable to palpate the uterine fundus of a client and notes a large amount of lochia on the perineal pad. Which intervention should the nurse implement first?

• A. Empty the bladder using an indwelling urinary catheter
• B. Increase the rate of the IV containing oxytocin (Pitocin)
• C. Assess for shock by determining the blood pressure
• D. Perform gentle massage at the level of the umbilicus

Correct answer: D

Rationale: Gentle massage at the level of the umbilicus is the initial intervention to help contract the uterus and reduce bleeding, which is crucial in managing postpartum hemorrhage. Emptying the bladder can help with fundal displacement, but massage should be done first to stimulate uterine contractions. Increasing the IV oxytocin rate is a possible intervention but not the initial priority. Assessing for shock is important, but addressing the uterine atony through massage takes precedence to prevent further hemorrhage.

3. The nurse is caring for a laboring 22-year-old primigravida following administration of regional anesthesia. In planning care for this client, what nursing intervention has the highest priority?

• A. Raising the side rails and placing the call bell within reach
• B. Teaching the client how to push effectively to decrease the length of the second stage of labor
• C. Timing and recording uterine contractions
• D. Positioning the client for proper distribution of anesthesia

Correct answer: A

Rationale: The highest priority nursing intervention for a laboring client following administration of regional anesthesia is to ensure safety by raising the side rails and placing the call bell within reach. This is crucial to prevent falls and to ensure that the client can call for assistance if needed. Teaching the client how to push effectively (Choice B) is important but not the highest priority at this moment. Timing and recording uterine contractions (Choice C) are essential but not as immediate as ensuring safety post-anesthesia. Positioning the client for proper distribution of anesthesia (Choice D) is important but ensuring immediate safety takes precedence in this situation.

4. A client with type 1 diabetes mellitus reports feeling shaky and has a blood glucose level of 60 mg/dl. What action should the nurse take?

• A. Administer 15 grams of carbohydrate
• B. Administer a glucagon injection
• C. Provide a snack with protein
• D. Encourage the client to rest

Correct answer: A

Rationale: The correct action for a client with type 1 diabetes mellitus experiencing hypoglycemia with a blood glucose level of 60 mg/dl is to administer 15 grams of carbohydrate. This will help raise the blood glucose levels quickly. Administering a glucagon injection (Choice B) is usually reserved for severe hypoglycemia where the client is unconscious or unable to swallow. Providing a snack with protein (Choice C) is not the first-line treatment for hypoglycemia as protein takes longer to raise blood glucose levels. Encouraging the client to rest (Choice D) may be beneficial after administering the carbohydrate, but the priority is to raise the blood glucose levels promptly.

5. What instruction is most important for the nurse to provide a female client who has just been diagnosed with trichomoniasis?

• A. Avoid douching
• B. Treat sexual partner(s) concurrently
• C. Avoid using moist washcloths when bathing
• D. Postpone becoming pregnant until the infection is treated

Correct answer: B

Rationale: The most important instruction for a female client diagnosed with trichomoniasis is to treat sexual partner(s) concurrently. This is crucial to prevent reinfection and the spread of the infection. Choice A, avoiding douching, is generally recommended for vaginal health but is not the most critical instruction in this case. Choice C, avoiding moist washcloths when bathing, is not directly related to the transmission or treatment of trichomoniasis. Choice D, postponing pregnancy until the infection is treated, is important but treating sexual partners concurrently takes precedence to prevent reinfection.

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