Nursing Elites

1. A nurse is collecting data from a postpartum client who had a vaginal birth 2 days ago. Which of the following findings is the nurse's priority to report to the provider?

• A. Bright red bleeding
• B. Burning with urination
• C. Headache
• D. Heavy lochia flow

Correct answer: B

Rationale: The correct answer is B: 'Burning with urination.' Burning with urination can indicate a urinary tract infection postpartum, which requires immediate attention to prevent complications. Bright red bleeding and heavy lochia flow are expected findings in the early postpartum period as the uterus continues to contract and expel lochia. A headache alone is not uncommon postpartum and is often attributed to hormonal changes, dehydration, or fatigue, and can be managed with adequate rest, hydration, and pain relief. Therefore, the priority here is to address the potential infection indicated by burning with urination.

2. Which of the following situations can be identified as an ethical dilemma?

• A. A nurse demonstrates signs of chemical impairment
• B. A family has conflicting feelings about tube feeding for their terminally ill father
• C. A nurse overhears a colleague threatening to restrain a patient if they do not stay in bed
• D. A client with terminal cancer hesitates to name their spouse as power of attorney

Correct answer: B

Rationale: The correct answer is B. Ethical dilemmas involve conflicting values or feelings. In this situation, the family is conflicted about tube feeding for their terminally ill father, which presents a moral and ethical challenge. Choices A, C, and D do not represent ethical dilemmas. Choice A involves a nurse's impairment, which is a different issue. Choice C involves a nurse's observation of a colleague's threat, which is a patient safety concern. Choice D involves a client's hesitation in naming a spouse as power of attorney, which is a legal and decision-making issue, not necessarily an ethical dilemma.

3. What are the risk factors for the development of pressure ulcers, and how can they be prevented?

• A. Immobility and poor nutrition
• B. Increased mobility and proper hygiene
• C. Excess moisture and lack of movement
• D. Frequent turning and repositioning

Correct answer: A

Rationale: The correct answer is A: Immobility and poor nutrition are significant risk factors for pressure ulcers. Immobility leads to prolonged pressure on certain body areas, increasing the risk of tissue damage. Poor nutrition can impair skin integrity and the body's ability to heal. Prevention strategies include frequent turning and repositioning to relieve pressure points. Choice B is incorrect because increased mobility actually reduces the risk of pressure ulcers. Choice C is incorrect as excess moisture can contribute to skin breakdown, but it is not a primary risk factor. Choice D is incorrect as frequent turning and repositioning are part of the prevention measures, not risk factors.

4. What are the risk factors for developing pneumonia in older adults?

• A. Immobility and decreased lung function
• B. Poor hygiene and aspiration
• C. Use of respiratory equipment and medications
• D. Poor nutritional status and compromised immune system

Correct answer: A

Rationale: The correct answer is A: Immobility and decreased lung function. Older adults with immobility and decreased lung function are at a higher risk of developing pneumonia. Immobility can lead to decreased lung expansion and impaired clearance of secretions, predisposing to pneumonia. While poor hygiene, aspiration, use of respiratory equipment, medications, poor nutritional status, and compromised immune system can also contribute to pneumonia risk, they are not as directly associated with pneumonia in older adults as immobility and decreased lung function.

5. What should a healthcare provider monitor in a client with constipation?

• A. Monitor the client's bowel sounds every 4 hours
• B. Increase the client's activity to stimulate bowel movement
• C. Encourage the client to use a stool softener
• D. Encourage the client to rest in bed until constipation resolves

Correct answer: C

Rationale: Encouraging the client to use a stool softener is the appropriate intervention for constipation. Stool softeners help to soften the stool, making it easier to pass and relieving constipation without straining the client. Monitoring bowel sounds (Choice A) may be relevant for other gastrointestinal issues but is not specifically indicated for constipation. Increasing activity (Choice B) can be helpful in some cases, but it is not the first-line intervention for constipation. Encouraging bed rest (Choice D) can worsen constipation by reducing mobility and promoting inactivity.

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