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. A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions should the nurse take?

• A. Shave hairy areas of skin prior to application.
• B. Wear gloves to apply the patch to the client's skin.
• C. Apply the patch within 1 hr of removing it from the protective pouch.
• D. Remove the previous patch and place it in a tissue.

Correct answer: B

Rationale: The correct answer is to wear gloves when applying the transdermal nicotine patch to prevent the nurse from absorbing nicotine through the skin. Choice A is incorrect because shaving hairy areas of skin is not necessary for applying a transdermal patch. Choice C is incorrect as transdermal patches should be applied immediately after removal from the protective pouch, not necessarily within 1 hour. Choice D is incorrect because the previous patch should be disposed of properly following institutional guidelines, not placed in a tissue.

3. Which of the following is a key consideration when caring for a client with heart failure on fluid restriction?

• A. Encourage the client to drink more fluids to stay hydrated
• B. Weigh the client daily to monitor fluid status
• C. Limit the client's intake of fruits and vegetables
• D. Monitor the client's fluid intake only during meals

Correct answer: B

Rationale: When caring for a client with heart failure on fluid restriction, weighing the client daily is crucial to monitor fluid balance accurately. This helps healthcare providers assess if the client is retaining excess fluids, which can worsen heart failure. Encouraging the client to drink more fluids (choice A) contradicts the goal of fluid restriction. Limiting intake of fruits and vegetables (choice C) is not a specific guideline for managing fluid restriction in heart failure. Monitoring fluid intake only during meals (choice D) is insufficient as fluid balance needs to be monitored consistently throughout the day.

4. A healthcare professional is caring for a client with coronary artery disease (CAD) who is prescribed aspirin. Which of the following findings should the healthcare professional report to the provider?

• A. A history of gastrointestinal bleeding
• B. A history of hypertension
• C. A platelet count of 180,000/mm³
• D. A prothrombin time (PT) of 12 seconds

Correct answer: A

Rationale: The correct answer is A: A history of gastrointestinal bleeding. Patients with a history of gastrointestinal bleeding are at increased risk of complications when taking aspirin due to its effects on platelet function and the gastrointestinal tract. Reporting this finding to the provider is crucial to ensure patient safety. Choices B, C, and D are not directly related to the increased risk associated with aspirin use in patients with a history of gastrointestinal bleeding, making them less relevant in this scenario. While monitoring platelet count and PT are important in patients taking aspirin, a history of gastrointestinal bleeding takes precedence as it directly impacts the safety and effectiveness of aspirin therapy in this client.

5. What intervention is key when managing a client with delirium?

• A. Administer antipsychotic medication to calm the client
• B. Identify any reversible causes of delirium
• C. Provide a low-stimulation environment
• D. Increase environmental stimulation

Correct answer: B

Rationale: The correct intervention when managing a client with delirium is to identify any reversible causes. Delirium can be caused by various factors such as infections, medications, dehydration, or metabolic imbalances. Administering antipsychotic medications (Choice A) may worsen delirium and should be avoided unless necessary for specific indications. Providing a low-stimulation environment (Choice C) is beneficial as it can help reduce agitation and confusion in individuals with delirium. Increasing environmental stimulation (Choice D) is contraindicated as it can exacerbate symptoms in delirious patients. Therefore, the priority should be on identifying and addressing reversible causes to effectively manage delirium.

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