Nursing Elites

1. A nurse is caring for a client who delivered a full-term newborn 16 hours ago. The nurse notes excessive lochia discharge. Which of the following actions should the nurse take first?

• A. Administer pain medication
• B. Perform a fundal massage
• C. Check the baby's heart rate
• D. Apply an ice pack

Correct answer: B

Rationale: Performing a fundal massage is the priority action in a postpartum client experiencing excessive lochia discharge. Fundal massage helps prevent postpartum hemorrhage by ensuring the uterus contracts effectively. Administering pain medication, checking the baby's heart rate, and applying an ice pack are not the initial interventions needed to address excessive lochia discharge.

2. What are the nursing responsibilities when administering intravenous (IV) antibiotics?

• A. Verify the antibiotic dosage and check for allergies
• B. Administer the medication without verification
• C. Do not check for allergies or dosage
• D. Ensure the patient is allergic to antibiotics

Correct answer: A

Rationale: When administering IV antibiotics, it is essential for the nurse to verify the antibiotic dosage and check for any allergies the patient may have. This is crucial to ensure that the correct medication is being given at the proper dose and to prevent potential adverse reactions. Choice B is incorrect because administering medication without verification can lead to errors. Choice C is incorrect as it goes against safe medication administration practices. Choice D is incorrect as the focus should be on checking if the patient has allergies to antibiotics, not ensuring the patient is allergic to them.

3. A healthcare professional is reviewing the laboratory report of a client who is receiving filgrastim. Which of the following laboratory values should the healthcare professional monitor to determine the effectiveness of the treatment?

• A. WBC count.
• B. Serum potassium.
• C. Hemoglobin level.
• D. Serum creatinine.

Correct answer: A

Rationale: Filgrastim works by stimulating the production of white blood cells. Therefore, monitoring the white blood cell (WBC) count is essential to assess the effectiveness of the treatment. Choice B, serum potassium, is not directly affected by filgrastim therapy. Choice C, hemoglobin level, is important but not the primary indicator of filgrastim's effectiveness. Choice D, serum creatinine, is unrelated to the action of filgrastim and would not reflect its effectiveness.

4. What is the most appropriate action for a healthcare provider to take when a patient is experiencing a seizure?

• A. Protect the patient's head
• B. Restrain the patient's movements
• C. Insert an airway
• D. Give the patient water

Correct answer: A

Rationale: During a seizure, the most appropriate action for a healthcare provider is to protect the patient's head. This helps prevent injury, especially considering the involuntary movements and potential thrashing associated with seizures. Restraint should be avoided as it can lead to further injury or distress for the patient. Inserting an airway is not recommended during an active seizure as the patient's airway may not be obstructed, and it could pose a risk of injury. Giving the patient water during a seizure is also not advisable as there is a risk of aspiration. Therefore, the priority is to ensure the patient's safety by protecting their head.

5. A healthcare professional is planning care for a client who has a prescription for mechanical restraints. Which of the following interventions should the healthcare professional include in the plan?

• A. Document the client's status every 60 minutes.
• B. Provide a staff member to stay with the client continuously.
• C. Measure vital signs every 4 hours.
• D. Obtain a prescription for the restraints every 8 hours.

Correct answer: B

Rationale: When a client has a prescription for mechanical restraints, it is essential to provide continuous monitoring for their safety and to observe any behavioral changes. Having a staff member stay with the client continuously allows for immediate intervention if needed. Documenting the client's status every 60 minutes (Choice A) may not provide real-time monitoring, which is crucial in this situation. While measuring vital signs every 4 hours (Choice C) is important, continuous observation takes precedence in this scenario. Obtaining a prescription for the restraints every 8 hours (Choice D) is not a necessary intervention once the initial prescription is in place.

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