Nursing Elites

1. An ambulatory client reports edema during the day in his feet and an ankle that disappears while sleeping at night. What is the most appropriate follow-up question for the nurse to ask?

• A. Have you had a recent heart attack?
• B. Do you become short of breath during your normal daily activities?
• C. How many pillows do you use at night to sleep comfortably?
• D. Do you smoke?

Correct answer: B

Rationale: The correct answer is asking about shortness of breath during normal daily activities because these symptoms suggest right-sided heart failure, leading to increased pressure in the systemic venous system. This pressure causes fluid to shift into the interstitial spaces, resulting in edema. In an ambulatory patient, lower extremities are typically affected first due to gravity. By asking about shortness of breath, the nurse can gather information to confirm the nursing diagnosis of activity intolerance and fluid volume excess, both associated with right-sided heart failure. The other choices are less relevant in this context and do not directly address the client's presenting symptoms.

2. On the first postpartum day, a client whose infant is rooming in asks the nurse to return her baby to the nursery and bring the baby to her only at feeding times. Which response would the nurse provide?

• A. It seems that you've changed your mind about rooming in.
• B. I think you're having difficulty caring for the baby.
• C. All right. I'll inform the other nurses of your decision.
• D. You must be tired. I'll bring the baby back at feeding time.

Correct answer: A

Rationale: Stating that it seems that the client has changed her mind opens communication and allows the client to verbalize her thoughts and feelings. This response acknowledges the client's request without being judgmental. Stating that the client is having difficulty caring for the baby is presumptuous and could make the client defensive. Informing other nurses of the client's decision without exploring the reasons behind it may not address the client's concerns. Although the client may be tired, assuming this without further discussion may overlook the client's true feelings and needs, hindering effective communication and support.

3. Which is the most appropriate nursing intervention when providing care for parents who have experienced a stillbirth?

• A. Giving a detailed explanation of possible causes of the stillbirth
• B. Providing the parents the opportunity to say goodbye to their newborn
• C. Explaining that an autopsy is not recommended in the setting of a stillbirth
• D. Arranging follow-up care and providing information to the parents before they leave the hospital

Correct answer: B

Rationale: The most appropriate nursing intervention when caring for parents who have experienced a stillbirth is to provide them with the opportunity to say goodbye to their newborn. This helps in the grieving process and allows the parents closure. Giving a detailed explanation of possible causes of the stillbirth may overwhelm the parents and is not the immediate priority. While an autopsy can be performed in the case of a stillbirth, the decision should be discussed with the parents and their wishes respected. Arranging follow-up care and providing information before the parents leave the hospital is crucial in ensuring they have the necessary support and resources to cope with the loss effectively.

4. The nurse plans to administer diazepam, 4 mg IV push, to a client with severe anxiety. How many milliliters should the nurse administer? (Round to the nearest tenth.)

• A. 0.2 mL
• B. 0.8 mL
• C. 1.25 mL
• D. 2.0 mL

Correct answer: B

Rationale: To calculate the volume to administer, use the formula: (Volume to administer = (Ordered Dose � Volume on hand) / Dose on hand). In this case, it would be (4 mg � 1 mL) / 5 mg = 0.8 mL. Therefore, the nurse should administer 0.8 mL of diazepam. Choice A (0.2 mL) is incorrect because it miscalculates the dosage. Choice C (1.25 mL) and Choice D (2.0 mL) are incorrect as they do not align with the correct calculation based on the ordered dose and available concentration. The correct answer, 0.8 mL, is derived from accurate dosage calculation and aligns with the formula for IV medication administration, ensuring the safe and effective delivery of the medication to the client.

5. A client experiences postpartum hemorrhage eight hours after the birth of twins. Following administration of IV fluids and 500 ml of whole blood, her hemoglobin and hematocrit are within normal limits. She asks the nurse whether she should continue to breastfeed the infants. Which of the following is based on sound rationale?

• A. Nursing will help contract the uterus and reduce your risk of bleeding.
• B. Breastfeeding twins will take too much energy after the hemorrhage.
• C. The blood transfusion may increase the risks to you and the babies.
• D. Lactation should be delayed until the 'real milk' is secreted.

Correct answer: A

Rationale: The correct answer is 'Nursing will help contract the uterus and reduce your risk of bleeding.' Stimulation of the breast during nursing releases oxytocin, which contracts the uterus. This contraction is especially important following hemorrhage. Choice B is incorrect because breastfeeding can actually help prevent further bleeding by promoting uterine contractions. Choice C is incorrect as the blood transfusion is aimed at restoring the client's blood volume and should not significantly impact the babies. Choice D is incorrect as lactation should not be delayed, as breastfeeding can provide numerous benefits to both the mother and infants, including aiding in the prevention of postpartum hemorrhage.

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