Nursing Elites

1. A postpartum client's fundus is firm, 3 cm above the umbilicus, and displaced to the right. Which of the following interventions should the nurse take?

• A. Massage the fundus
• B. Administer oxytocin
• C. Assist the client to void then reassess the fundus
• D. Notify the healthcare provider

Correct answer: C

Rationale: The correct intervention for a postpartum client with a firm, displaced fundus is to assist the client to void then reassess the fundus. Displacement of the uterus to the right is often a sign of bladder distention, which can prevent the uterus from contracting properly and increase the risk of postpartum hemorrhage. By helping the client to void, the nurse can alleviate the bladder distention, allowing the uterus to contract effectively. Massaging the fundus (Choice A) may not address the underlying issue of bladder distention. Administering oxytocin (Choice B) is not indicated without assessing and addressing the cause of the displacement. Notifying the healthcare provider (Choice D) is premature before implementing initial nursing interventions to address the potential cause of the displaced fundus.

2. A nurse is performing a cultural assessment of a group of clients to maintain respect for their value systems and beliefs. Which of the following should the nurse identify as examples of cultural variables?

• A. Eye contact
• B. Personal space
• C. Touch
• D. All of the above

Correct answer: D

Rationale: In a cultural assessment, it is essential to consider various cultural variables that can impact communication and interactions. Eye contact, personal space, and touch are examples of cultural variables that can vary among different cultural groups. These variables influence how individuals perceive and engage in communication. Understanding and respecting these differences are crucial for effective and culturally sensitive care. Therefore, the correct answer is 'All of the above.' Choices A, B, and C are incorrect because each of them represents a cultural variable that should be considered during a cultural assessment.

3. A client newly prescribed sertraline is being taught by a nurse. Which statement by the client indicates understanding?

• A. I should take this medication with meals.
• B. I might have trouble sleeping when I start this medication.
• C. I should avoid drinking orange juice.
• D. I will feel better immediately after starting the medication.

Correct answer: B

Rationale: Choice B, 'I might have trouble sleeping when I start this medication,' indicates understanding because insomnia is a common side effect of sertraline, especially when initiating the medication. This statement shows the client comprehends a potential adverse effect and is prepared for it. Choices A, C, and D are incorrect. Taking sertraline with or without meals does not significantly affect its efficacy. There is no specific contraindication about drinking orange juice while on sertraline. Feeling better immediately after starting the medication is unlikely as sertraline usually takes some time to exert its therapeutic effects.

4. A client with a history of renal failure is being cared for by a nurse. Which of the following should the nurse monitor?

• A. Fluid intake
• B. Electrolyte levels
• C. Blood pressure
• D. Both B and C

Correct answer: D

Rationale: Clients with renal failure are at risk for electrolyte imbalances and hypertension. Monitoring electrolyte levels is crucial because renal failure can lead to imbalances in sodium, potassium, and other electrolytes. Blood pressure monitoring is essential as hypertension is a common complication of renal failure. Therefore, both electrolyte levels and blood pressure should be closely monitored to detect and manage any abnormalities. Fluid intake, while important, is not specific to renal failure monitoring and is not the priority in this case.

5. A client is prescribed insulin glargine. Which of the following should the nurse instruct the client to do regarding administration of this medication?

• A. Inject insulin glargine 30 minutes before a meal.
• B. Shake the insulin vial before administration.
• C. Administer insulin glargine once daily at bedtime.
• D. Take insulin glargine with short-acting insulin.

Correct answer: C

Rationale: The correct answer is C: Administer insulin glargine once daily at bedtime. Insulin glargine is a long-acting insulin that provides a basal level of insulin throughout the day. It should be given at the same time each day, usually at bedtime, to maintain a consistent blood sugar level. Choices A, B, and D are incorrect. Injecting insulin glargine before a meal (Choice A) is not necessary as it is a long-acting insulin. Shaking the insulin vial (Choice B) is not recommended as it may cause bubbles to form, affecting the accuracy of the dose. Taking insulin glargine with short-acting insulin (Choice D) is not a typical practice as insulin glargine is used for basal insulin coverage.

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