Nursing Elites

1. As you are assessing the fetus during labor, you are determining the fetal lie, presentation, attitude, station, and position. Your client asks you what all these assessments are. Among other things, how should you respond to the mother?

• A. You should explain that fetal lie is where the fetus's presenting part is within the birth canal during labor, among other information about the other assessments.
• B. You should explain that fetal presentation is the relationship of the fetus's spine to the mother's spine, among other information about the other assessments.
• C. You should explain that fetal attitude is the relationship of the fetus's presenting part to the anterior, posterior, right, or left side of the mother's pelvis, among other information about the other assessments.
• D. You should explain that fetal station is the level of the fetus's presenting part in relationship to the mother's ischial spines, among other information about the other assessments.

Correct answer: D

Rationale: You should explain that fetal station is the level of the fetus's presenting part in relationship to the mother's ischial spines. Fetal station is measured in terms of the number of centimeters above or below the mother's ischial spines. When the fetus is 1 to 5 centimeters above the ischial spines, the fetal station is -1 to -5, and when the fetus is 1 to 5 centimeters below the level of the maternal ischial spines, the fetal station is +1 to +5. Choices A, B, and C provide incorrect information about fetal lie, presentation, and attitude, respectively, which do not align with the definitions of these terms in obstetrics.

2. Your patient has been diagnosed with a left ankle sprain. On the discharge instructions, the physician has prescribed the RICE protocol. This acronym stands for:

• A. Rest, Ice, Compression, Elevation
• B. Radiology, Ice, Compression, Elevation
• C. Rest, Ice, Cast, Elevation
• D. Radiology, Ice, Cast, Elevation

Correct answer: A

Rationale: The correct answer is Rest, Ice, Compression, Elevation. This acronym, RICE, is commonly used for the treatment of injuries like an ankle sprain. Rest allows the injured area to heal, Ice helps reduce swelling and pain (20 minutes on each hour while awake), Compression is usually achieved with an elastic bandage to minimize swelling, and Elevation of the foot above the level of the heart assists in reducing swelling and promoting healing. Choices B, C, and D are incorrect because they include irrelevant terms like Radiology and Cast, which are not part of the standard treatment protocol for an ankle sprain.

3. A client needs to give informed consent for electroconvulsive therapy treatments. Which of the following actions should the nurse take?

• A. Explain the adverse effects the client might experience from the treatment
• B. Verify the client gave consent voluntarily for the treatment
• C. Describe the benefits of the treatment to the client
• D. Outline possible alternatives to the treatment for the client

Correct answer: B

Rationale: When obtaining informed consent for a procedure like electroconvulsive therapy, the nurse's primary responsibility is to ensure that the client has given consent voluntarily and is capable of making such a decision. While it is essential to provide information on the treatment's benefits, risks, and alternatives, the priority is to verify the client's voluntary consent. Explaining the adverse effects and describing the benefits are important steps in the informed consent process, but the critical step is to confirm the client's voluntary agreement. Outlining possible alternatives to the treatment is also important but comes after ensuring the client's voluntary consent.

4. Upon admission to the stroke care unit of a rehabilitation center, what is the primary action of the nurse?

• A. Collect and organize documents for the client's medical record
• B. Prepare the client's identification bracelet
• C. Identify pertinent health history data and current needs and limitations
• D. Gather the client's valuables and secure them in a locked container

Correct answer: C

Rationale: When a client is admitted to a stroke care unit in a rehabilitation center, the nurse's initial priority is to assess the client. This assessment includes identifying relevant health history data that may impact the client's care. By recognizing the client's current needs and limitations, the nurse can develop a comprehensive understanding of the client's condition. This information is crucial for generating a nursing diagnosis and establishing appropriate care outcomes. While collecting and organizing documents for the medical record, preparing identification bracelets, and securing valuables are important tasks, they are not the primary actions that directly influence the client's immediate care upon admission.

5. A nurse is caring for an 83-year-old man who has had swallowing difficulties. All of the following interventions are appropriate for this client EXCEPT:

• A. Keep the client in an upright position at all times
• B. Auscultate lung sounds every shift and after feedings
• C. Maintain suction equipment at the client's bedside
• D. Instruct the client about how to perform swallowing exercises

Correct answer: A

Rationale: When caring for a client with swallowing difficulties, it is crucial to prevent aspiration of food into the lungs. Appropriate interventions include auscultating lung sounds every shift and after feedings to assess for any changes in breathing patterns, maintaining suction equipment at the client's bedside in case of difficulties, and providing instruction on swallowing exercises. Keeping the client in an upright position at all times is not necessary and may not always be feasible or comfortable for the client. This rigid requirement is not part of the standard care protocol for managing swallowing difficulties.

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