Nursing Elites

1. A nurse is observing bonding between the client and her newborn. Which of the following actions by the client requires the nurse to intervene?

• A. Holding the newborn in an en face position
• B. Asking the father to change the newborn's diaper
• C. Requesting the nurse to take the newborn to the nursery so she can rest
• D. Viewing the newborn’s actions as uncooperative

Correct answer: D

Rationale: The correct answer is D because viewing the newborn’s actions as uncooperative indicates a negative interaction with the newborn and suggests impaired bonding, which requires intervention. Choices A, B, and C are not indicative of impaired bonding. Holding the newborn in an en face position is a positive way to bond with the baby. Asking the father to change the diaper shows involvement of both parents in caring for the newborn, which is beneficial for bonding. Requesting the nurse to take the newborn to the nursery so the mother can rest is a normal request and does not necessarily indicate impaired bonding.

2. A client receiving oxytocin IV for labor augmentation is experiencing contractions every 45 seconds. What action should the nurse take?

• A. Discontinue the oxytocin infusion
• B. Increase the oxytocin infusion
• C. Decrease the oxytocin infusion
• D. Maintain the oxytocin infusion

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to discontinue the oxytocin infusion. Contractions occurring every 45 seconds indicate uterine hyperstimulation, which can pose risks to both the client and the fetus. By stopping the oxytocin infusion, the nurse can help prevent further complications. Choices B, C, and D are incorrect because increasing, decreasing, or maintaining the oxytocin infusion can exacerbate the uterine hyperstimulation and increase the risks associated with it.

3. A client with rheumatoid arthritis is taking prednisone. Which of the following findings should the nurse identify as an adverse effect of this medication?

• A. Weight loss
• B. Hypoglycemia
• C. Hypertension
• D. Hyperkalemia

Correct answer: C

Rationale: The correct answer is C: Hypertension. Prednisone, a corticosteroid, can lead to hypertension as an adverse effect. Prednisone can cause sodium and water retention, leading to increased blood pressure. Options A, B, and D are incorrect. Weight loss is not typically associated with prednisone use; instead, weight gain is more common. Hypoglycemia is not a common adverse effect of prednisone; in fact, it can elevate blood sugar levels. Hyperkalemia is also not a typical adverse effect of prednisone; instead, it can cause hypokalemia, or low potassium levels.

4. A nurse is providing teaching to a client who has a new prescription for warfarin. Which of the following statements by the client indicates a need for further teaching?

• A. I will take ibuprofen for headaches.
• B. I will use an electric razor to shave.
• C. I will avoid eating large amounts of leafy green vegetables.
• D. I will have my blood levels checked regularly.

Correct answer: A

Rationale: The correct answer is A. Ibuprofen can increase the risk of bleeding when taken with warfarin, as both medications affect clotting. The client should use alternative pain relievers like acetaminophen. Choice B is correct as using an electric razor is a safe choice to prevent cuts that could lead to bleeding. Choice C is correct as warfarin interacts with vitamin K found in leafy green vegetables. Choice D is correct as regular blood level checks are necessary to monitor the effects and adjust the warfarin dosage if needed.

5. During a breast examination on a 24-year-old client, the nurse notes the following findings. Which finding is of most concern and should be reported to the provider?

• A. An irregularly shaped, nontender lump palpable in the right breast
• B. Tenderness present during menstruation
• C. Bilateral, symmetrical lumps that move with palpation
• D. The client reports breast tenderness before menstruation

Correct answer: A

Rationale: An irregularly shaped, nontender lump is a concerning finding as it may indicate breast cancer. The nurse should report this finding to the provider for further investigation. Choices B, C, and D are less concerning findings. Tenderness during menstruation is a common finding due to hormonal changes. Bilateral, symmetrical lumps that move with palpation are often benign findings like fibrocystic changes. Breast tenderness before menstruation is also a common occurrence related to hormonal fluctuations.

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