Nursing Elites

1. A nurse in a prenatal clinic is educating a client about expected changes during pregnancy. The nurse should instruct the client about which change during pregnancy is related to the slowing of the gastrointestinal tract?

• A. Diarrhea
• B. Constipation
• C. Decreased absorption of iron
• D. Decreased absorption of calcium

Correct answer: B

Rationale: During pregnancy, the hormonal changes can lead to the slowing down of the gastrointestinal tract, causing constipation. This occurs due to increased progesterone levels, which relax smooth muscles, including those in the intestines, leading to slower bowel movements. Diarrhea is not typically associated with the slowing of the gastrointestinal tract during pregnancy. While there may be changes in the absorption of nutrients like iron and calcium, they are not directly related to the slowing of the gastrointestinal tract.

2. What is the first step in decontamination?

• A. Immediately applying a chemical decontamination foam to the area of contamination
• B. Thoroughly washing and rinsing the patient with soap and water
• C. Immediately applying personal protective equipment
• D. Removing the patient's clothing and jewelry, then rinsing the patient with water

Correct answer: D

Rationale: The correct first step in decontamination is to remove the patient's clothing and jewelry to prevent further exposure and then rinse the patient with water. This helps to eliminate any contaminants on the patient's body. Choice A is incorrect because applying a chemical decontamination foam should come after removing clothing. Choice B is incorrect as washing and rinsing the patient should follow the removal of clothing. Choice C is incorrect as personal protective equipment should be worn by the individual performing the decontamination, not applied to the patient.

3. In some hip surgeries, an epidural catheter for Fentanyl epidural analgesia is given. What is your nursing priority care in such a case?

• A. Instruct the client to observe strict bed rest
• B. Check for epidural catheter drainage
• C. Administer analgesia through the epidural catheter as prescribed
• D. Assess respiratory rate carefully

Correct answer: D

Rationale: The nursing priority care in a case where an epidural catheter for Fentanyl epidural analgesia is given during hip surgeries is to assess the respiratory rate carefully. Respiratory depression is a potential side effect of Fentanyl, especially when administered epidurally. Monitoring the respiratory rate is crucial to detect any signs of respiratory distress promptly. Instructing the client to observe strict bed rest (Choice A) may be necessary but is not the priority over ensuring respiratory function. Checking for epidural catheter drainage (Choice B) and administering analgesia through the epidural catheter as prescribed (Choice C) are important aspects of care, but ensuring adequate ventilation takes precedence to prevent complications.

4. What nursing diagnosis would be most appropriate for a patient with heart failure?

• A. risk for infection
• B. fluid volume excess
• C. impaired body temperature
• D. ineffective airway clearance

Correct answer: B

Rationale: The most appropriate nursing diagnosis for a patient with heart failure is 'fluid volume excess.' In heart failure, the heart's reduced pumping ability leads to fluid retention, causing an excess of fluid in the body. This can result in symptoms such as edema, shortness of breath, and weight gain. 'Risk for infection,' 'impaired body temperature,' and 'ineffective airway clearance' are not the most appropriate nursing diagnoses for a patient with heart failure as they do not directly relate to the pathophysiology and common issues seen in heart failure patients.

5. Which practice is a type of traditional Chinese medicine?

• A. magnet therapy
• B. acupuncture
• C. faith healing
• D. biofeedback

Correct answer: B

Rationale: Acupuncture is a key practice in traditional Chinese medicine. It involves the insertion of thin needles into specific points on the body to balance energy flow and promote healing. Magnet therapy, faith healing, and biofeedback are not specifically associated with traditional Chinese medicine practices.

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