Nursing Elites

1. A nurse is assessing a client 2 hours after a vaginal delivery and notes that the client's uterus is boggy and displaced to the right. Which of the following interventions should the nurse perform first?

• A. Assist the client to void
• B. Massage the uterus
• C. Administer oxytocin
• D. Encourage breastfeeding

Correct answer: A

Rationale: A boggy and displaced uterus is often a sign of bladder distention, which can prevent the uterus from contracting effectively. The priority intervention is to assist the client to void. By emptying the bladder, the uterus can return to midline and become firm. Massaging the uterus or administering oxytocin may be necessary but should come after addressing the bladder distention. Encouraging breastfeeding is important for uterine contraction but is not the priority in this situation.

2. A nurse is planning care for a client who has Parkinson’s disease and is at risk for aspiration. Which of the following actions should the nurse include in the plan of care?

• A. Encourage the client to eat thin liquids
• B. Instruct the client to tilt their head forward when swallowing
• C. Give the client large pieces of food
• D. Have the client lie down after meals

Correct answer: B

Rationale: The correct action the nurse should include in the plan of care for a client with Parkinson’s disease at risk for aspiration is to instruct the client to tilt their head forward when swallowing. This action helps protect the airway and reduces the risk of aspiration in clients with impaired swallowing, which is common in Parkinson’s disease. Encouraging the client to eat thin liquids (Choice A) can increase the risk of aspiration as they are harder to control during swallowing. Giving the client large pieces of food (Choice C) can also increase the risk of choking and aspiration. Having the client lie down after meals (Choice D) can further increase the risk of aspiration due to the potential for reflux. Therefore, the best action to prevent aspiration in this situation is to instruct the client to tilt their head forward when swallowing.

3. A healthcare professional is preparing to administer a dose of sertraline. Which of the following should the healthcare professional assess first?

• A. Blood pressure
• B. Heart rate
• C. Respiratory rate
• D. Mood changes

Correct answer: A

Rationale: When administering sertraline, assessing blood pressure is crucial as this medication can potentially affect blood pressure levels. Monitoring blood pressure before giving sertraline helps ensure patient safety and allows for appropriate interventions if any significant changes are noted. Heart rate, respiratory rate, and mood changes are important assessments but are not typically the first priority when administering sertraline. While heart rate and respiratory rate can also be affected by sertraline, blood pressure assessment is a higher priority due to the medication's known effects on blood pressure regulation.

4. A nurse is reviewing a client's medical record and notes that the client is taking tamoxifen. The nurse should identify that tamoxifen is used to treat which of the following conditions?

• A. Non-Hodgkin's lymphoma
• B. Endometriosis
• C. Breast cancer
• D. Polycystic ovary syndrome

Correct answer: C

Rationale: Tamoxifen is an anti-estrogen medication primarily used to treat hormone receptor-positive breast cancer. It works by blocking estrogen receptors in breast tissue, slowing the growth of tumors that require estrogen to grow. Choice A, Non-Hodgkin's lymphoma, is incorrect because tamoxifen is not indicated for its treatment. Choice B, Endometriosis, is incorrect as tamoxifen is not used for this condition. Choice D, Polycystic ovary syndrome, is also incorrect since tamoxifen is not a treatment for this syndrome.

5. A nurse is planning an education session for a client who has type 1 diabetes mellitus. Which of the following should the nurse plan to include when teaching the client to monitor for hypoglycemia?

• A. Diaphoresis
• B. Polyuria
• C. Abdominal pain
• D. Thirst

Correct answer: A

Rationale: The correct answer is A: Diaphoresis. Diaphoresis (sweating) is a classic symptom of hypoglycemia, along with shakiness, confusion, and irritability. These signs help indicate low blood sugar levels. Choices B, C, and D are incorrect. Polyuria (excessive urination), abdominal pain, and thirst are not typical symptoms associated with hypoglycemia. It is crucial for clients with type 1 diabetes mellitus to recognize the early signs of hypoglycemia to take prompt corrective action.

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