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. When performing an admission assessment of a client diagnosed with a brain tumor, which question is most important for the nurse to ask the client?

• A. When did your symptoms first begin?
• B. Can you describe the pain and how it feels?
• C. Do you have any changes in vision?
• D. Have you experienced any seizures?

Correct answer: D

Rationale: The correct answer is D. When assessing a client diagnosed with a brain tumor, asking about seizures is crucial because they can be a common symptom associated with brain tumors. Seizures in this context could provide valuable information regarding the progression and impact of the brain tumor on the client's neurological status. Choices A, B, and C are important questions in a general assessment, but when specifically focusing on a client with a brain tumor, inquiring about seizures takes priority due to its direct relevance to the condition.

3. An 18-year-old gravida 1, at 41-weeks gestation, is undergoing an oxytocin (Pitocin) induction and has an epidural catheter in place for pain control. With each of the last three contractions, the nurse notes a late deceleration. The client is repositioned and oxygen provided, but the late decelerations continue to occur with each contraction. What action should the nurse take first?

• A. Prepare for immediate cesarean birth
• B. Turn off the oxytocin (Pitocin) infusion
• C. Notify the anesthesiologist that the epidural infusion needs to be disconnected
• D. Apply an internal fetal monitoring device and continue to monitor carefully

Correct answer: B

Rationale: In the scenario described, the presence of late decelerations during contractions indicates fetal compromise. To address this, the nurse's initial action should be to turn off the oxytocin (Pitocin) infusion. Oxytocin can contribute to uteroplacental insufficiency, leading to late decelerations. This intervention aims to improve fetal oxygenation and prevent further stress on the fetus. Immediate cesarean birth is not the first-line action unless other interventions fail. Notifying the anesthesiologist about disconnecting the epidural infusion is not the priority in this situation. Applying an internal fetal monitoring device is invasive and not the immediate step needed when late decelerations are present.

4. The nurse is caring for a client who is receiving heparin therapy. Which laboratory value should the nurse monitor to determine the effectiveness of the therapy?

• A. Prothrombin time (PT)
• B. Partial thromboplastin time (PTT)
• C. International normalized ratio (INR)
• D. Activated partial thromboplastin time (aPTT)

Correct answer: C

Rationale: The correct answer is C, International Normalized Ratio (INR). While INR is commonly used to monitor the effectiveness of warfarin therapy, in the case of heparin therapy, the Partial Thromboplastin Time (PTT) is the preferred test. Choice A, Prothrombin Time (PT), measures the activity of the extrinsic pathway of coagulation and is not the best choice for monitoring heparin therapy. Choice D, Activated Partial Thromboplastin Time (aPTT), is similar to PTT and is used to monitor heparin therapy, but PTT is the more specific test. Therefore, monitoring PTT is crucial in determining the effectiveness and safety of heparin therapy.

5. The nurse preceptor is orienting a new graduate nurse to the critical care unit. The preceptor asks the new graduate to state symptoms that most likely indicate the beginning of a shock state in a critically ill client. What findings should the new graduate nurse identify?

• A. Tachycardia, mental status change, and low urine output
• B. Warm skin, hypertension, and constricted pupils
• C. Bradycardia, hypotension, and respiratory acidosis
• D. Mottled skin, tachypnea, and hyperactive bowel sounds

Correct answer: A

Rationale: The correct answer is A: Tachycardia, mental status change, and low urine output are early signs of shock. Tachycardia is the body's compensatory mechanism to maintain perfusion, mental status changes can indicate decreased cerebral perfusion, and low urine output reflects poor renal perfusion. Choices B, C, and D are incorrect. Warm skin, hypertension, and constricted pupils are not typical findings in the early stages of shock. Bradycardia, hypotension, and respiratory acidosis are more indicative of late-stage shock. Mottled skin, tachypnea, and hyperactive bowel sounds can be seen in various conditions but are not specific early signs of shock.

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