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 is receiving enoxaparin for the prevention of DVT. Which of the following is an appropriate action by the nurse?

• A. Expel any air bubbles from the prefilled syringe
• B. Massage the injection site to aid in absorption of the medication
• C. Inject the medication into the lateral abdominal wall
• D. Administer an NSAID for injection site discomfort

Correct answer: C

Rationale: The correct answer is to inject enoxaparin into the lateral abdominal wall for subcutaneous absorption. This site is commonly used for administering this type of medication. Expelling air bubbles from the syringe is not necessary and may result in a reduced dose being administered. Massaging the injection site is not recommended as it can lead to bruising or irritation. Administering an NSAID for injection site discomfort is not indicated as discomfort at the injection site is usually minimal and self-limiting.

3. A healthcare professional is assessing a client who is experiencing a thyroid storm. Which of the following is an expected finding?

• A. Hypothermia
• B. Bradycardia
• C. Hypertension
• D. Lethargy

Correct answer: C

Rationale: In a thyroid storm, which is a severe complication of hyperthyroidism, hypertension is an expected finding. Other common manifestations include tachycardia, hyperthermia, and agitation. Hypothermia (choice A) is not expected in a thyroid storm as the body temperature is usually elevated due to increased metabolic rate. Bradycardia (choice B) is not typical in a thyroid storm; instead, tachycardia is more common. Lethargy (choice D) is not a typical finding in a thyroid storm, as clients are usually agitated due to excess thyroid hormone levels.

4. A nurse is preparing to administer TPN with added fat supplements to a client who has malnutrition. Which of the following actions should the nurse take?

• A. Administer the TPN solution separately from 0.9% sodium chloride
• B. Check for an allergy to eggs
• C. Discuss the TPN solution with the client
• D. Monitor for hypoglycemia

Correct answer: B

Rationale: The correct action for the nurse to take when preparing to administer TPN with fat supplements is to check for an allergy to eggs. The lipid emulsion in TPN often contains egg phospholipids, so screening for egg allergies is crucial to prevent any adverse reactions. Option A is incorrect because TPN should not be piggybacked with 0.9% sodium chloride to avoid any interactions or dilution of the TPN solution. Option C is incorrect as discussing the TPN solution with the client is not the priority when preparing to administer it. Option D is incorrect as monitoring for hypoglycemia, although important in TPN administration, is not specifically related to the addition of fat supplements.

5. A nurse is caring for a 7-month-old infant being treated for severe dehydration. Which finding indicates treatment has been effective?

• A. Skin turgor displays tenting
• B. Flat anterior fontanel
• C. Cool, mottled skin
• D. Hyperpnea

Correct answer: B

Rationale: A flat anterior fontanel indicates improved hydration in infants, as dehydration typically causes sunken fontanels.

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