Nursing Elites

1. A client who is at 24 weeks of gestation is being taught about the signs of preterm labor. Which of the following should the nurse include?

• A. Sudden weight loss
• B. Regular contractions
• C. Shortness of breath
• D. Vaginal spotting

Correct answer: B

Rationale: The correct answer is B: Regular contractions. Regular contractions before 37 weeks of gestation are a significant sign of preterm labor. It is essential for clients to be aware of this symptom and report it promptly to their healthcare provider. Choices A, C, and D are incorrect because sudden weight loss, shortness of breath, and vaginal spotting are not typical signs of preterm labor. Teaching clients about the specific signs of preterm labor can help in early detection and intervention, ultimately improving outcomes for both the client and the baby.

2. A nurse is caring for an older adult client with delirium. Which intervention will most effectively reduce the client's risk for falls?

• A. Using a night-light
• B. Demonstrating how to use the call light
• C. Placing the bedside table in close proximity
• D. Hourly rounding by the nurse

Correct answer: D

Rationale: Hourly rounding by the nurse is the most effective intervention to reduce the risk of falls in older adult clients with delirium. This intervention ensures that the nurse regularly checks on the client, assesses their needs, and assists them with any activities, thereby minimizing the chances of falls. Using a night-light (choice A) may help improve visibility but does not provide continuous assistance and monitoring. Demonstrating how to use the call light (choice B) is important but may not prevent falls directly. Placing the bedside table in close proximity (choice C) is helpful for convenience but does not address the continuous monitoring and assistance needed to prevent falls in this case.

3. Before an amniocentesis, what action by the client will need to be completed?

• A. Increase fluid intake
• B. Empty the bladder
• C. Avoid eating for 12 hours
• D. Take a sedative

Correct answer: B

Rationale: Before an amniocentesis, the client should empty their bladder. This is necessary to reduce the risk of bladder puncture during the procedure. A full bladder can be in the path of the needle, increasing the risk of injury. Increasing fluid intake (choice A) is not necessary before an amniocentesis. Avoiding eating for 12 hours (choice C) is not a standard preparation for an amniocentesis. Taking a sedative (choice D) is not routinely required for this procedure.

4. A healthcare provider is assessing a client who has severe dehydration. Which finding indicates effective treatment?

• A. Sunken anterior fontanel
• B. Tenting skin turgor
• C. Flat anterior fontanel
• D. Hyperpnea

Correct answer: C

Rationale: A flat anterior fontanel indicates effective treatment for dehydration in infants. Dehydration often causes sunken fontanels, so when the anterior fontanel becomes flat, it suggests that rehydration has occurred. Sunken anterior fontanel (Choice A) is a sign of dehydration, not effective treatment. Tenting skin turgor (Choice B) is also a sign of dehydration, indicating poor skin turgor. Hyperpnea (Choice D) is increased depth and rate of breathing and is not directly related to the hydration status of the client.

5. A nurse is admitted to a psychiatric unit and fails to follow her medication regimen. What does this behavior indicate?

• A. Early cognitive impairment
• B. Lack of motivation
• C. Lack of health literacy
• D. Worsening health state

Correct answer: C

Rationale: The correct answer is C, 'Lack of health literacy.' The nurse's inability to follow the medication regimen suggests she may lack health literacy, meaning she may not fully understand how to manage her own health care. Choice A, 'Early cognitive impairment,' is not supported by the information provided in the question as there is no mention of cognitive decline. Choice B, 'Lack of motivation,' is less likely as the behavior is more indicative of a knowledge deficit rather than a lack of drive. Choice D, 'Worsening health state,' is also less likely as the behavior described does not directly imply a worsening health condition but rather a misunderstanding or lack of knowledge on managing health.

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