Nursing Elites

1. A menopausal client is having difficulty getting to sleep and asks what actions she should incorporate into her daily routine to promote sleep. The nurse would encourage which of the following measures to promote sleep?

• A. Consume a warm drink at bedtime
• B. Take an evening walk before bedtime
• C. Take an afternoon nap
• D. Limit alcohol and nicotine prior to bedtime

Correct answer: D

Rationale: The correct answer is D: Limit alcohol and nicotine prior to bedtime. Alcohol and nicotine are stimulants that can disrupt sleep patterns, so avoiding them before bedtime can promote better sleep. Choices A, B, and C are incorrect. Consuming a warm drink at bedtime may lead to frequent urination, disrupting sleep; taking an evening walk before bedtime may increase alertness rather than inducing sleep; and taking an afternoon nap can make it harder to fall asleep at night.

2. A client newly diagnosed with asthma is receiving discharge instructions from a nurse. Which statement by the client indicates an understanding of the teaching?

• A. I will use my fluticasone inhaler to treat asthma attacks.
• B. I will use a peak flow meter once a week.
• C. I will keep a diary of when I use my albuterol inhaler.
• D. I will limit my fluid intake to prevent mucus production.

Correct answer: C

Rationale: The correct answer is C. Keeping a diary of albuterol use helps monitor the frequency and severity of asthma symptoms, which can guide the healthcare provider in adjusting treatment as needed. Option A is incorrect because fluticasone is a controller medication used for long-term management, not for treating acute asthma attacks. Option B is incorrect as using a peak flow meter once a week may not provide real-time information on asthma control. Option D is incorrect as limiting fluid intake does not directly prevent mucus production in asthma.

3. What is the nurse's next action after a laboring client's membranes have just ruptured?

• A. Assess fetal heart rate pattern
• B. Monitor uterine contractions
• C. Administer oxygen
• D. Prepare for delivery

Correct answer: A

Rationale: After a laboring client's membranes have ruptured, the nurse's immediate priority is to assess the fetal heart rate pattern. This assessment is crucial to ensure the fetus is not in distress, especially to rule out umbilical cord compression that could affect blood flow to the fetus. While monitoring uterine contractions is important, assessing the fetal heart rate takes precedence in this situation as it directly reflects the fetus's well-being. Administering oxygen may be necessary later depending on the fetal status, and preparing for delivery should only occur if the assessment indicates fetal distress or other complications. Therefore, the correct next action for the nurse is to assess the fetal heart rate pattern.

4. A nurse is caring for a toddler with respiratory syncytial virus (RSV). Which action should the nurse take?

• A. Use a designated stethoscope for the toddler
• B. Wear an N95 respirator mask when caring for the toddler
• C. Place the toddler in a negative pressure room
• D. Remove the disposable gown before leaving the toddler's room

Correct answer: A

Rationale: Using a designated stethoscope for the toddler is crucial to reduce the risk of spreading RSV to other patients. Choice B is incorrect because N95 respirator masks are not specifically indicated for RSV. Choice C is unnecessary as RSV does not require isolation in a negative pressure room. Choice D is incorrect because the gown should be removed after leaving the room to prevent transmission of pathogens to other areas.

5. A nurse is performing a focused assessment for a client who has dysrhythmias. What indicates ineffective cardiac contractions?

• A. Increased blood pressure
• B. Pulse deficit
• C. Normal heart rate
• D. Elevated oxygen saturation

Correct answer: B

Rationale: The correct answer is B: Pulse deficit. A pulse deficit is a significant finding in clients with dysrhythmias, indicating ineffective cardiac contractions. Pulse deficit occurs when there is a difference between the apical and radial pulses, suggesting that not all heart contractions are strong enough to produce a pulse that can be felt peripherally. Increased blood pressure (choice A) may occur due to various factors and is not a direct indicator of ineffective cardiac contractions. Similarly, a normal heart rate (choice C) and elevated oxygen saturation (choice D) do not specifically point towards ineffective cardiac contractions; they can be present in individuals with dysrhythmias but do not directly indicate ineffective cardiac contractions.

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