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 client with GERD is receiving discharge instructions from a nurse. Which statement by the client indicates an understanding of the teaching?

• A. “I should take my medicine with orange juice.”
• B. “Having a bedtime snack will prevent heartburn.”
• C. “I will lie down after meals.”
• D. “I will limit activities that require bending at the waist.”

Correct answer: D

Rationale: The correct answer is D. Limiting activities that require bending at the waist can help prevent episodes of reflux in clients with GERD. Choices A, B, and C are incorrect. Taking medicine with orange juice may not be appropriate as citrus juices can aggravate GERD. Having a bedtime snack can exacerbate heartburn by increasing stomach acid production, and lying down after meals can worsen symptoms of GERD by allowing stomach acid to flow back into the esophagus.

3. A nurse is caring for a client receiving heparin. Which of the following should the nurse monitor?

• A. INR levels
• B. APTT levels
• C. Blood glucose levels
• D. Liver function tests

Correct answer: B

Rationale: Heparin therapy requires monitoring of activated partial thromboplastin time (APTT) to ensure therapeutic levels. APTT reflects the intrinsic pathway of the clotting cascade and is used to assess the effectiveness and safety of heparin therapy. Monitoring INR levels is more relevant for assessing warfarin therapy, not heparin. Blood glucose levels are monitored for clients with diabetes or those on medications affecting glucose levels. Liver function tests are used to assess liver health and are not directly related to monitoring heparin therapy.

4. A nurse is discussing immunity with a client who has received an immunization. The nurse should identify that an immunization functions as part of which of the following types of immunity?

• A. Innate immunity
• B. Passive immunity
• C. Acquired immunity
• D. Natural immunity

Correct answer: C

Rationale: Immunizations provide acquired immunity. They work by introducing antigens into the body, which triggers the immune system to produce antibodies specific to that antigen. Choice A, 'Innate immunity,' refers to the natural defense mechanisms an organism is born with and does not involve immunizations. Choice B, 'Passive immunity,' is the transfer of pre-formed antibodies and does not involve immunizations. Choice D, 'Natural immunity,' is a general term that encompasses all immunity that is not acquired through deliberate immunization or passive transfer of antibodies.

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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