Nursing Elites

1. A nurse is assessing a client 1 hour after birth and notes a boggy uterus located 2 cm above the umbilicus. What should the nurse do first?

• A. Take vital signs
• B. Assess lochia
• C. Massage the fundus
• D. Give oxytocin IV bolus

Correct answer: C

Rationale: A boggy uterus located 2 cm above the umbilicus suggests uterine atony, which is a common cause of postpartum hemorrhage. The initial intervention in this situation is to massage the fundus. Fundal massage helps the uterus contract, promoting hemostasis and preventing excessive bleeding. Taking vital signs or assessing lochia are important actions but are secondary to addressing uterine atony. Administering oxytocin IV bolus is often done after fundal massage to further enhance uterine contractions.

2. A client tells the nurse that she suspects she is pregnant because she is able to feel the baby move. The nurse knows that this is a:

• A. Presumptive sign of pregnancy
• B. Probable sign of pregnancy
• C. Positive sign of pregnancy
• D. Possible sign of pregnancy

Correct answer: A

Rationale: The correct answer is A: Presumptive sign of pregnancy. Quickening, or the sensation of fetal movement, is considered a presumptive sign of pregnancy. It is not definitive because other conditions, such as gas or intestinal movement, can mimic the feeling of fetal movement. Choice B, Probable sign of pregnancy, refers to signs that make the nurse reasonably certain that a woman is pregnant, such as a positive pregnancy test. Choice C, Positive sign of pregnancy, includes signs like hearing fetal heart tones or visualizing the fetus on ultrasound, which definitively confirm pregnancy. Choice D, Possible sign of pregnancy, is a vague term and does not specifically relate to any pregnancy sign.

3. A healthcare professional is assessing a client for signs of depression. Which of the following findings should the healthcare professional look for?

• A. Increased energy
• B. Changes in sleep patterns
• C. Weight loss
• D. Both B and C

Correct answer: D

Rationale: When assessing a client for signs of depression, healthcare professionals should look for changes in sleep patterns and weight loss. These are common symptoms associated with depression. Increased energy (choice A) is not typically a sign of depression, as individuals with depression often experience fatigue and a lack of energy. Therefore, choices A, B, and C are incorrect, making choice D the correct answer.

4. A client with type 1 DM is being taught about hypoglycemia by a nurse. Which statement by the client indicates an understanding of the teaching?

• A. “Exercise decreases the risk of hypoglycemia.”
• B. “I should skip my insulin if I don't eat.”
• C. “I can drink 4 oz of regular soda if my blood sugar is low.”
• D. “Oral diabetic medications do not lead to hypoglycemia; only insulin does.”

Correct answer: C

Rationale: The correct answer is C because the client should have a quick-acting source of 15 g of carbohydrates to treat hypoglycemic episodes, such as 4 oz of regular soda. Choice A is incorrect because while exercise can help manage blood sugar levels, it can also increase the risk of hypoglycemia if not properly managed. Choice B is incorrect as skipping insulin when not eating can lead to hyperglycemia, not prevent hypoglycemia. Choice D is incorrect because certain oral diabetic medications can indeed cause hypoglycemia, not just insulin.

5. A healthcare professional is reviewing the health history of an older adult who has a hip fracture. What is a risk factor for developing pressure injuries?

• A. Dehydration
• B. Urinary incontinence
• C. Poor nutrition
• D. Poor tissue perfusion

Correct answer: B

Rationale: Urinary incontinence is a risk factor for developing pressure injuries due to prolonged skin exposure to moisture and irritants. Dehydration (choice A) can contribute to skin dryness but is not a direct risk factor for pressure injuries. Poor nutrition (choice C) can affect wound healing but is not specifically linked to pressure injuries. Poor tissue perfusion (choice D) can increase the risk of tissue damage but is not as directly associated with pressure injuries as urinary incontinence.

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