Nursing Elites

1. A nurse is assessing a client who gave birth 1 week ago. The client states, 'I don't know what's wrong. I love my baby, but I feel so let down and I seem to cry for no reason.' The nurse should identify that the client is experiencing which of the following emotional responses to birth?

• A. Postpartum depression
• B. Taking-in phase
• C. Postpartum blues
• D. Taking-hold phase

Correct answer: C

Rationale: The client is experiencing postpartum blues, not postpartum depression. Postpartum blues are common and characterized by mood swings, tearfulness, and emotional letdown shortly after delivery. The 'Taking-in phase' involves the mother focusing on her own needs, while the 'Taking-hold phase' is characterized by a desire to learn and feel competent in caring for the baby. Postpartum depression is a more severe and long-lasting condition that requires professional intervention.

2. A nurse is caring for a client who is hyperventilating and has the following ABG results: pH 7.50, PaCO2 29 mm Hg, and HCO3- 25 mEq/L. The nurse should recognize that the client has which of the following acid-base imbalances?

• A. Respiratory acidosis
• B. Respiratory alkalosis
• C. Metabolic acidosis
• D. Metabolic alkalosis

Correct answer: B

Rationale: The correct answer is B: Respiratory alkalosis. In this scenario, the client is hyperventilating, leading to excessive elimination of carbon dioxide. As a result, the PaCO2 decreases, causing a decrease in hydrogen ion concentration and an increase in pH, resulting in respiratory alkalosis. Choice A, Respiratory acidosis, is incorrect because the ABG results show a low PaCO2, not an elevated one. Choices C and D, Metabolic acidosis and Metabolic alkalosis, do not align with the ABG results provided, which point towards a respiratory, not metabolic, imbalance.

3. A nurse on the medical-surgical unit is receiving reports on four clients. Which of the following clients should the nurse assess first?

• A. A client who is receiving warfarin and has an INR of 3.3
• B. A client who has acute kidney injury, creatinine 4 mg/dL, and BUN 52 mg/dL
• C. A client who had an NG tube inserted 6 hours ago and has abdominal distention
• D. A client who is 4 hours postoperative following a thyroidectomy and reports fullness in the throat

Correct answer: D

Rationale: The client who is 4 hours postoperative following a thyroidectomy and reports fullness in the throat should be assessed first. This client may be experiencing airway obstruction due to hematoma or swelling, making it a priority. Options A, B, and C have concerning findings as well, but airway compromise takes precedence over other issues.

4. A patient scheduled for cataract surgery tells the nurse, 'I see just fine and have decided to cancel my surgery.' Which response should the nurse make?

• A. Tell the patient they need the surgery
• B. Encourage the patient to express their thoughts
• C. Ignore the comment and proceed
• D. Insist the patient needs to proceed with the surgery

Correct answer: B

Rationale: Encouraging the patient to express their thoughts is the best response in this situation. It allows the patient to voice their concerns or reasons for canceling the surgery, which can help the healthcare team address any misunderstandings or fears the patient may have. Choices A and D are too directive and do not consider the patient's autonomy and right to make informed decisions about their care. Choice C is inappropriate as it disregards the patient's expressed decision and fails to address the underlying issue.

5. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following assessment findings requires immediate intervention by the nurse?

• A. Prealbumin level of 20 mg/dL
• B. Weight increase of 2 kg/day
• C. Temperature of 37.6°C
• D. Blood glucose level of 120 mg/dL

Correct answer: B

Rationale: A rapid weight gain of 2 kg/day suggests fluid overload, a possible complication of TPN. This requires immediate intervention to prevent further complications such as pulmonary edema. The other options are not indicative of immediate complications related to TPN. A low prealbumin level may indicate malnutrition but does not require immediate intervention. A slightly elevated temperature and blood glucose level are within normal ranges and do not warrant immediate action.

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