Nursing Elites

1. A nurse is assisting with monitoring a client who is in labor and has spontaneous rupture of membranes following a vaginal examination. The provider reports the client's cervix is dilated to 1 cm with an unengaged presenting part. Which of the following actions should the nurse take?

• A. Encourage the client to bear down
• B. Apply the external fetal monitor
• C. Provide the client with fluids
• D. Administer IV fluids

Correct answer: B

Rationale: In this scenario, with the client's cervix dilated to only 1 cm and an unengaged presenting part, the priority action is to apply the external fetal monitor. This allows for continuous monitoring of the fetal heart rate during early labor, which is crucial for assessing fetal well-being. Encouraging the client to bear down is not appropriate at 1 cm dilation, as it may not be effective and can lead to exhaustion. Providing the client with fluids or administering IV fluids may be necessary for hydration, but the immediate concern is monitoring fetal well-being.

2. A client who is newly diagnosed with iron deficiency anemia needs to include foods rich in iron in their diet. Which of the following foods should the nurse recommend as having the highest amount of iron?

• A. Boiled spinach
• B. Raw carrots
• C. Boiled chicken
• D. Yogurt

Correct answer: A

Rationale: Boiled spinach is an excellent source of iron, making it a top choice for individuals with iron deficiency anemia. Spinach contains non-heme iron, which may not be absorbed as efficiently as heme iron from animal sources but is still beneficial. Raw carrots, boiled chicken, and yogurt are not as rich in iron compared to spinach. Carrots are more known for their beta-carotene content, chicken is a good source of protein but not high in iron, and yogurt does not contain significant amounts of iron.

3. A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which of the following findings should the nurse expect?

• A. Polyuria.
• B. Dehydration.
• C. Hyponatremia.
• D. Hyperglycemia.

Correct answer: C

Rationale: The correct answer is C: Hyponatremia. In SIADH, there is excessive release of antidiuretic hormone, causing water retention and dilutional hyponatremia. Polyuria (choice A) is increased urination, which is not a typical finding in SIADH. Dehydration (choice B) is the loss of body fluids, which is opposite to the fluid retention seen in SIADH. Hyperglycemia (choice D) is elevated blood sugar levels and is not directly related to SIADH.

4. The physician orders risperidone (Risperdal) for a client with Alzheimer's disease. The nurse anticipates administering this medication to help decrease which of the following behaviors?

• A. Sleep disturbances
• B. Concomitant depression
• C. Agitation and assaultiveness
• D. Confusion and withdrawal

Correct answer: C

Rationale: The correct answer is C: Agitation and assaultiveness. Risperidone is commonly prescribed for clients with Alzheimer's disease to reduce symptoms of agitation and aggressive behavior. This medication helps in managing challenging behaviors often seen in individuals with Alzheimer's. Choice A, sleep disturbances, is incorrect as risperidone is not primarily indicated for treating sleep issues in Alzheimer's patients. Choice B, concomitant depression, is also incorrect as risperidone is not the first-line treatment for depression in Alzheimer's disease. Choice D, confusion and withdrawal, is incorrect as risperidone does not directly target these symptoms in Alzheimer's patients.

5. A nurse is caring for a client who is experiencing chronic pain. Which of the following interventions should the nurse implement?

• A. Provide the client with distractions such as television
• B. Administer pain medication around the clock
• C. Teach the client relaxation techniques
• D. Perform massage therapy on the client

Correct answer: C

Rationale: The correct intervention for a client experiencing chronic pain is to teach relaxation techniques, as it helps in managing pain more effectively by reducing stress and anxiety. Distractions like television (Choice A) may offer temporary relief but do not address the root cause of chronic pain. Administering pain medication around the clock (Choice B) may lead to dependency and not promote long-term pain management. While massage therapy (Choice D) can be beneficial, teaching relaxation techniques (Choice C) is more directly focused on empowering the client to manage their pain independently.

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