Nursing Elites

1. A nurse is caring for a client who is 2 hours postpartum following a vaginal birth. The client reports heavy bleeding and passing large clots. What is the priority action for the nurse to take?

• A. Administer oxytocin IV
• B. Perform fundal massage
• C. Check vital signs
• D. Encourage the client to void

Correct answer: B

Rationale: Performing fundal massage is the priority action to take in this situation. Fundal massage helps stimulate uterine contractions, which can reduce postpartum bleeding. Uterine atony, the most common cause of early postpartum hemorrhage, can be addressed effectively through fundal massage. Administering oxytocin IV, although important, should come after initiating fundal massage. Checking vital signs is also crucial but not the immediate priority. Encouraging the client to void does not directly address the heavy bleeding and passing of large clots; hence, it is not the priority action.

2. A client is being treated with thiazide diuretics. What should the nurse monitor regularly?

• A. Hyperkalemia
• B. Hypokalemia
• C. Hyponatremia
• D. Hypoglycemia

Correct answer: B

Rationale: Thiazide diuretics are known to cause hypokalemia by increasing potassium excretion in the urine. Therefore, the nurse should monitor the client for low potassium levels. Hyperkalemia (Choice A) is not typically associated with thiazide diuretics. Hyponatremia (Choice C) is more commonly linked with thiazide diuretics due to increased sodium excretion. Hypoglycemia (Choice D) is not a usual concern when a client is receiving thiazide diuretics.

3. While caring for a newborn under phototherapy lights, what is an appropriate nursing action?

• A. Ensure an eye shield is covering the eyes
• B. Apply lotion to the exposed skin
• C. Offer glucose water between feedings
• D. Discontinue breastfeeding during treatment

Correct answer: A

Rationale: The correct answer is to ensure an eye shield is covering the eyes. This action is essential to protect the newborn's eyes from the bright light used in phototherapy. Applying lotion to the exposed skin (Choice B) is not necessary and may interfere with the treatment. Offering glucose water between feedings (Choice C) is not indicated and may not be appropriate for a newborn undergoing phototherapy. Discontinuing breastfeeding during treatment (Choice D) is not recommended as breastfeeding should be continued unless contraindicated.

4. A healthcare professional is assessing a client for signs of respiratory distress. Which of the following findings should the healthcare professional look for?

• A. Shallow breathing
• B. Bradycardia
• C. Increased appetite
• D. Warm, dry skin

Correct answer: A

Rationale: Corrected Question: A healthcare professional is assessing a client for signs of respiratory distress. Shallow breathing is a key indicator of respiratory distress, reflecting an inadequate exchange of oxygen and carbon dioxide. Bradycardia (Choice B) refers to a slow heart rate and is not typically a direct sign of respiratory distress. Increased appetite (Choice C) and warm, dry skin (Choice D) are unrelated to respiratory distress. Therefore, the correct answer is A.

5. A client with a cystocele is encouraged to exercise to strengthen pelvic floor muscles and prevent pelvic organ prolapse. What exercise will the client need to perform?

• A. Kegel exercises
• B. Isometric exercises
• C. Circumduction exercises
• D. Uterine extension exercises

Correct answer: A

Rationale: Corrected Rationale: The client with a cystocele should perform Kegel exercises to strengthen the pelvic floor muscles, reducing the risk of pelvic organ prolapse and stress urinary incontinence. Kegel exercises specifically target the muscles that support the pelvic organs. Isometric exercises focus on static muscle contractions and may not be as effective as Kegel exercises for strengthening the pelvic floor. Circumduction exercises involve circular movements at joints and are not specific to pelvic floor muscle strengthening. Uterine extension exercises do not directly target the pelvic floor muscles and are not indicated for cystocele management.

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