Nursing Elites

1. A nurse is caring for four clients. Which of the following client data should the nurse report to the provider?

• A. Client who has pleurisy and reports pain of 6 on a scale of 0 to 10
• B. Client with 110 mL of serosanguineous fluid from a Jackson Pratt drain within the first 24 hours after surgery
• C. Client who is 4 hours postoperative and has a heart rate of 98 bpm
• D. Client who has a prescription for chemotherapy and an absolute neutrophil count of 75/mm3

Correct answer: D

Rationale: An absolute neutrophil count of 75/mm3 indicates severe neutropenia, which puts the client at high risk of infection and requires immediate intervention. Neutropenia increases the susceptibility to infections due to a significant decrease in neutrophils, which are essential for fighting off bacteria and other pathogens. Reporting this critical lab value promptly to the provider is essential to ensure appropriate interventions are initiated to prevent life-threatening infections. Choices A, B, and C do not present immediate life-threatening conditions that require urgent reporting to the provider.

2. A nurse is caring for a client in active labor who is receiving oxytocin. The nurse notes that the client is experiencing contractions every 1 minute lasting 90 seconds. Which of the following actions should the nurse take?

• A. Stop the oxytocin infusion
• B. Administer oxygen
• C. Increase the IV fluid rate
• D. Prepare for delivery

Correct answer: A

Rationale: The correct action the nurse should take in this situation is to stop the oxytocin infusion. Contractions occurring every 1 minute lasting 90 seconds indicate uterine hyperstimulation, which can lead to fetal distress by compromising oxygen supply. Stopping the oxytocin infusion will help reduce the frequency and intensity of contractions, allowing for better fetal oxygenation. Administering oxygen (Choice B) may be necessary if there are signs of fetal distress, but stopping the oxytocin is the priority. Increasing IV fluid rate (Choice C) is not the appropriate action in response to hyperstimulation. While preparing for delivery (Choice D) may eventually be necessary, the immediate action should be to address the hyperstimulation by stopping the oxytocin infusion.

3. A client is being educated by a nurse on how to use a PCA pump postoperatively. Which statement by the client indicates understanding?

• A. I should wait until the pain is severe before using the PCA pump.
• B. My family can press the button for me while I’m asleep.
• C. I will press the button when I start to feel pain.
• D. I will only press the button once per hour.

Correct answer: C

Rationale: The correct answer is C. This statement indicates understanding because the client recognizes that they should use the PCA pump when they start to feel pain. Waiting for the pain to become severe is not recommended as it may lead to inadequate pain control. Option B is incorrect because only the client should control the PCA pump to ensure safety and appropriate dosing. Option D is also incorrect as there is no set limit on how often the button can be pressed, as it should be used as needed when pain is felt.

4. A client is experiencing urinary incontinence, and a nurse is providing care. Which of the following recommendations should the nurse include in the teaching plan for this client?

• A. Drink large amounts of water before bedtime
• B. Perform Kegel exercises regularly
• C. Limit fiber intake in the diet to avoid bowel irritation
• D. Increase intake of caffeinated and carbonated beverages

Correct answer: B

Rationale: The correct recommendation for a client experiencing urinary incontinence is to perform Kegel exercises regularly. These exercises help strengthen the pelvic floor muscles, improving bladder control and reducing urinary incontinence. Option A is incorrect because drinking large amounts of water before bedtime can worsen urinary incontinence by increasing urine production. Option C is incorrect as fiber is important for bowel health and limiting it may not be beneficial for the client. Option D is incorrect as caffeinated and carbonated beverages can irritate the bladder and worsen urinary incontinence, so they should be avoided.

5. A client with lactose intolerance needs to increase calcium intake. Which food should the nurse recommend?

• A. Spinach
• B. Peanut butter
• C. Ground beef
• D. Carrots

Correct answer: A

Rationale: Spinach is a suitable choice to recommend for increasing calcium intake to a client with lactose intolerance. Spinach is a good non-dairy source of calcium. Peanut butter, ground beef, and carrots are not significant sources of calcium. Peanut butter is high in protein and fats, ground beef is a source of protein and iron, and carrots are rich in vitamin A and fiber, but none of these choices provide a substantial amount of calcium.

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