Nursing Elites

1. A client with a history of depression is experiencing a situational crisis. Which of the following actions should the nurse take first?

• A. Confirm the client's perception of the event.
• B. Notify the client's support system.
• C. Help the client identify personal strengths.
• D. Teach the client relaxation techniques.

Correct answer: A

Rationale: The correct answer is to confirm the client's perception of the event. In crisis intervention, understanding the client's perspective is crucial as it helps the nurse assess the situation accurately and provide tailored support. This step can also help build rapport and trust with the client. Option B, notifying the client's support system, may be important but should come after assessing the client's perception. Option C, helping the client identify personal strengths, and option D, teaching relaxation techniques, are valuable interventions but should follow the initial step of confirming the client's perception.

2. A nurse is planning care for a client who has a stage 2 pressure injury. Which of the following interventions should the nurse include?

• A. Cleanse the wound with povidone-iodine.
• B. Apply a hydrocolloid dressing.
• C. Perform debridement as needed.
• D. Keep the wound open to air.

Correct answer: B

Rationale: The correct answer is B: Apply a hydrocolloid dressing. Applying a hydrocolloid dressing helps create a moist environment that promotes healing in clients with stage 2 pressure injuries. Choice A, cleansing the wound with povidone-iodine, is not recommended for stage 2 pressure injuries as it can be too harsh on the skin. Performing debridement as needed, as mentioned in choice C, is not typically indicated for stage 2 pressure injuries, which involve partial-thickness skin loss. Keeping the wound open to air, as stated in choice D, is also not the preferred approach for managing stage 2 pressure injuries, as maintaining a moist environment is key to promoting healing.

3. A client is being discharged with a new prescription for metoprolol. Which of the following instructions should the nurse include?

• A. Do not discontinue this medication suddenly.
• B. Take this medication in the evening to decrease the risk of falls.
• C. Monitor your heart rate before taking this medication.
• D. Avoid grapefruit juice while taking this medication.

Correct answer: C

Rationale: The correct instruction for a client prescribed metoprolol is to monitor their heart rate before taking the medication. Metoprolol is a beta-blocker that can cause bradycardia (slow heart rate), so it is essential for clients to check their heart rate before each dose. Choice A is incorrect because abruptly stopping metoprolol can lead to adverse effects, so it should not be discontinued suddenly. Choice B is incorrect because there is no specific recommendation to take metoprolol at night to reduce falls. Choice D is incorrect because grapefruit juice can interact with metoprolol, affecting its absorption, and should be avoided.

4. A nurse is providing teaching to a client who is at 36 weeks of gestation and is scheduled for a nonstress test. Which of the following instructions should the nurse include?

• A. The test will last about 30 minutes.
• B. You should drink a full glass of water prior to the test.
• C. You will need to have your bladder full for this test.
• D. This test measures how well your baby's heart responds to movement.

Correct answer: D

Rationale: The correct answer is D. A nonstress test measures the fetal heart's response to movement, helping to assess fetal well-being. Choice A is incorrect as the duration of the test can vary, and it is not always precisely 30 minutes. Choice B is incorrect as drinking water is not necessary for a nonstress test. Choice C is incorrect as having a full bladder is not required for this test.

5. A nurse is assessing a client who is in active labor, and the FHR baseline has been 100/min for 15 minutes. What should the nurse suspect?

• A. Maternal fever.
• B. Fetal anemia.
• C. Maternal hypoglycemia.
• D. Chorioamnionitis.

Correct answer: C

Rationale: The correct answer is C: Maternal hypoglycemia. Maternal hypoglycemia can lead to fetal bradycardia, which is indicated by a baseline FHR of 100/min. In this scenario, the sustained low baseline FHR suggests a possible link to maternal hypoglycemia. Maternal fever (Choice A) typically presents with tachycardia rather than bradycardia in the fetus. Fetal anemia (Choice B) usually causes fetal tachycardia as a compensatory mechanism to deliver more oxygen to tissues. Chorioamnionitis (Choice D) is associated with maternal fever and an elevated fetal heart rate, not a sustained low baseline FHR.

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