Nursing Elites

1. A nurse is caring for a pregnant client in the labor unit who suddenly experiences spontaneous rupture of the membranes. On inspecting the amniotic fluid, the nurse notes that it is clear, with creamy white flecks. What is the most appropriate action for the nurse to take based on this finding?

• A. Check the client's temperature.
• B. Report the findings to the nurse-midwife.
• C. Obtain a sample of the amniotic fluid for laboratory analysis.
• D. Document the findings.

Correct answer: D

Rationale: Amniotic fluid should be clear and may include bits of vernix, the creamy white fetal skin lubricant. Therefore, the nurse would most appropriately document the findings. Checking the client's temperature, reporting the findings to the nurse-midwife, and obtaining a sample of the amniotic fluid for laboratory analysis are not necessary in this situation. Cloudy, yellow, or foul-smelling amniotic fluid suggests infection, while green fluid indicates that the fetus passed meconium before birth. If abnormalities are noted, the nurse should notify the nurse-midwife.

2. A client is given an opiate drug for pain relief following general anesthesia. The client becomes extremely somnolent with respiratory depression. The physician is likely to order the administration of:

• A. naloxone (Narcan)
• B. labetalol (Normodyne)
• C. neostigmine (Prostigmin)
• D. thiothixene (Navane)

Correct answer: A

Rationale: In this scenario, the client is experiencing respiratory depression due to opiate overdose. Naloxone (Narcan) is an opioid antagonist that can rapidly reverse the effects of opiates by competitively binding to opioid receptors and displacing the opiates. This action can restore normal respiration and consciousness. Labetalol (Normodyne) is a non-selective beta-blocker used to manage hypertension, not opioid-induced respiratory depression. Neostigmine (Prostigmin) is a cholinesterase inhibitor used to reverse neuromuscular blockade, not opioid overdose. Thiothixene (Navane) is an antipsychotic medication used to manage psychotic disorders, not opioid toxicity.

3. A paraplegic client is in the hospital to be treated for an electrolyte imbalance. Which level of care is the client currently receiving?

• A. primary prevention
• B. secondary prevention
• C. tertiary prevention
• D. health promotion

Correct answer: B

Rationale: The correct answer is B: secondary prevention. The client is currently receiving secondary prevention care. Secondary prevention focuses on early detection of disease, prompt intervention, and health maintenance for clients experiencing health problems. In this case, the electrolyte imbalance is a health problem that requires treatment to prevent further complications. Choices A, C, and D are incorrect because primary prevention is focused on health promotion and specific protections against illness before it occurs, tertiary prevention is aimed at helping rehabilitate clients after the illness is diagnosed and treated, and health promotion is a broader concept that includes activities aimed at improving overall health and well-being rather than targeting a specific health problem like an electrolyte imbalance.

4. When assessing the health-related physical fitness of a client as part of a health assessment, what aspect should be the focus?

• A. agility
• B. speed
• C. body composition
• D. risk factors

Correct answer: D

Rationale: When assessing the health-related physical fitness of a client, the primary focus should be on identifying risk factors that could predispose the client to illness or injury. Risk factors are crucial in determining an individual's overall health status and potential health outcomes. While agility, speed, and body composition are important components of physical fitness assessments, they are not the primary focus when assessing health-related physical fitness from a holistic perspective. Therefore, the correct choice is 'risk factors.'

5. When performing an abdominal assessment, what is the correct order of the tasks?

• A. inspect, percuss, palpate, auscultate
• B. inspect, palpate, percuss, auscultate
• C. inspect, auscultate, percuss, palpate
• D. inspect, palpate, auscultate, percuss

Correct answer: C

Rationale: The correct order of tasks when performing an abdominal assessment is to first inspect the abdomen visually, then auscultate to assess bowel sounds without altering them, followed by percussing to assess the presence of tympany or dullness, and finally palpating to feel for any tenderness, masses, or organ enlargement. Placing palpation or percussion before auscultation, as in choices A, B, and D, can affect the bowel sounds and examination findings, making them incorrect sequences.

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