Nursing Elites

1. A client who signed an informed consent form for surgery but has since expressed doubts about the need for surgery is being assisted by a nurse. Which of the following statements should the nurse make?

• A. You should not worry about it
• B. The surgeon will answer your questions before surgery
• C. It’s too late to cancel the surgery
• D. You need to trust the medical team

Correct answer: B

Rationale: The correct answer is B because the nurse should encourage the client to express concerns and ensure that the surgeon addresses any questions prior to the procedure. Choice A is incorrect as it dismisses the client's worries. Choice C is incorrect because it does not respect the client's autonomy in decision-making. Choice D is incorrect as it does not address the client's doubts directly or provide reassurance.

2. A charge nurse is teaching a new nurse how to clean surfaces contaminated with blood. Which agent should the charge nurse include in the teaching?

• A. Hydrogen peroxide
• B. Chlorhexidine
• C. Isopropyl alcohol
• D. Chlorine bleach

Correct answer: D

Rationale: Chlorine bleach is the most appropriate agent for disinfecting surfaces contaminated with blood. It is effective in killing a wide range of pathogens, including viruses. Hydrogen peroxide (Choice A) is not as effective as chlorine bleach for bloodborne pathogen disinfection. Chlorhexidine (Choice B) and isopropyl alcohol (Choice C) are more commonly used for skin antisepsis rather than surface disinfection, making them less suitable options in this scenario.

3. A nurse is planning care for a client who has a new diagnosis of deep vein thrombosis (DVT). Which action should the nurse take?

• A. Massage the affected extremity
• B. Elevate the affected leg
• C. Apply cold packs to the affected leg
• D. Keep the leg dependent to increase circulation

Correct answer: B

Rationale: Elevating the leg promotes venous return and reduces swelling, which is crucial for clients with DVT. Massaging the affected extremity can dislodge the clot and worsen the condition. Applying cold packs can cause vasoconstriction, potentially increasing the risk of clot formation. Keeping the leg dependent can impede circulation and increase the risk of clot migration.

4. A patient with chronic kidney disease reports feeling light-headed after taking their medication. What should the nurse instruct the patient to do?

• A. Take the medication with food
• B. Take the medication at bedtime
• C. Stand up slowly to prevent dizziness
• D. Increase fluid intake

Correct answer: C

Rationale: Patients with chronic kidney disease are prone to orthostatic hypotension, which can cause dizziness. To prevent this, the nurse should instruct the patient to stand up slowly. Options A, B, and D do not directly address the issue of orthostatic hypotension and dizziness in this scenario.

5. A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations of the FHR. Which of the following actions should the nurse take first?

• A. Prepare the equipment necessary to initiate an amnioinfusion
• B. Administer oxygen at 10 L/min via a non-rebreather face mask
• C. Discontinue the infusion of oxytocin
• D. Place the client in a left lateral position

Correct answer: C

Rationale: The correct first action for the nurse to take is to discontinue the infusion of oxytocin. Oxytocin can lead to uterine hyperstimulation and fetal distress, contributing to variable decelerations in fetal heart rate. By stopping the oxytocin infusion, the nurse can promptly assess and manage the fetal heart rate. Choice A, preparing for amnioinfusion, is not the priority when faced with recurrent variable decelerations. Choice B, administering oxygen, is important but addressing the oxytocin infusion issue takes precedence. Choice D, placing the client in a left lateral position, is beneficial for optimizing fetal oxygenation but discontinuing oxytocin is the initial step in managing variable decelerations.

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