Nursing Elites

1. A nurse is caring for a client who is 24 hr postpartum and is breastfeeding her newborns. The client asks the nurse to warm up seaweed soup that the client's partner brought for her. Which of the following responses should the nurse make?

• A. Does the doctor know you are eating that?
• B. Why are you eating seaweed soup?
• C. Of course I will heat that up for you.
• D. The hospital food is more nutritious.

Correct answer: C

Rationale: Respecting cultural dietary preferences enhances patient-centered care.

2. A nurse overhears two assistive personnel (AP) discussing care for a client in the elevator. What action should the nurse take?

• A. Contact the client's family about the incident.
• B. Notify the client's provider about the incident.
• C. File a complaint with the ethics committee.
• D. Report the incident to the AP's charge nurse.

Correct answer: D

Rationale: The correct action for the nurse to take in this situation is to report the incident to the AP's charge nurse. This ensures that the issue is addressed internally and allows for proper handling of the situation. Contacting the client's family about the incident (Choice A) may not be appropriate as it could breach confidentiality and escalate the situation unnecessarily. Notifying the client's provider (Choice B) is not the most immediate and effective step to address the issue. Filing a complaint with the ethics committee (Choice C) should be reserved for serious ethical violations, and in this case, reporting to the charge nurse is the more practical and immediate course of action.

3. A nurse is planning care for a client who is receiving hemodialysis. Which action should the nurse include in the care plan?

• A. Withhold all medications until after dialysis.
• B. Rehydrate with dextrose 5% in water for orthostatic hypotension.
• C. Check the vascular access site for bleeding after dialysis.
• D. Give an antibiotic 30 minutes before dialysis.

Correct answer: C

Rationale: The correct action the nurse should include in the care plan for a client receiving hemodialysis is to check the vascular access site for bleeding after dialysis. This is crucial as it helps in detecting and addressing any bleeding complications that may arise from the dialysis procedure. Choice A is incorrect because medications should not be withheld unless specified by the healthcare provider. Choice B is incorrect as dextrose 5% in water is not typically used for orthostatic hypotension. Choice D is incorrect as giving an antibiotic before dialysis is not a routine practice unless specifically prescribed for a particular reason.

4. A nurse is preparing to administer vancomycin IV to a client. Which of the following actions should the nurse take?

• A. Administer the medication over 30 minutes.
• B. Monitor the client for a decrease in blood pressure during administration.
• C. Assess the IV site for infiltration during administration.
• D. Premedicate the client with an antiemetic prior to administration.

Correct answer: C

Rationale: The correct action the nurse should take when administering vancomycin IV is to assess the IV site for infiltration during administration. Vancomycin is known to cause tissue damage if it infiltrates, making close monitoring crucial. Administering the medication over 30 minutes (Choice A) is a common practice but not the priority in preventing infiltration. Monitoring for a decrease in blood pressure (Choice B) is not directly related to vancomycin administration. Premedicating with an antiemetic (Choice D) is not typically required for vancomycin administration.

5. A client is 4 hours postpartum. Which of the following interventions should be implemented to prevent postpartum hemorrhage?

• A. Monitor for signs of infection.
• B. Massage the uterus every 4 hours.
• C. Apply ice packs to the perineum.
• D. Administer methylergonovine IM.

Correct answer: D

Rationale: Administering methylergonovine intramuscularly helps contract the uterus, reducing the risk of postpartum hemorrhage. Monitoring for signs of infection (Choice A) is important but not directly related to preventing postpartum hemorrhage. Uterine massage (Choice B) is beneficial to prevent uterine atony, but methylergonovine is a more specific intervention to prevent hemorrhage. Applying ice packs to the perineum (Choice C) is helpful for perineal pain and swelling, not for preventing postpartum hemorrhage.

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