Nursing Elites

1. Based on the information provided in this client’s medical record during labor, which intervention should the nurse implement?

• A. Apply oxygen at 10 L per minute via mask
• B. Stop the oxytocin infusion
• C. Turn the client to the right lateral position
• D. Continue monitoring the progress of labor

Correct answer: C

Rationale: Turning the client to the right lateral position is essential as it can improve fetal oxygenation and uterine blood flow, promoting better labor outcomes. This intervention helps relieve pressure on blood vessels, enhancing blood flow to the placenta and improving oxygen supply to the fetus. Applying oxygen at a specific rate may not address the underlying issue of compromised blood flow and oxygenation. Stopping the oxytocin infusion is not the priority unless medically indicated as it can affect labor progression. While monitoring the progress of labor is important, actively addressing the compromised fetal oxygenation and uterine blood flow by changing the client's position takes precedence in this scenario.

2. A client who is diagnosed with amyotrophic lateral sclerosis (ALS) is having difficulty swallowing and articulating words. Which intervention is most important to include in this client’s plan of care?

• A. Encourage speaking slowly and articulating words
• B. Sit upright and flex chin forward while swallowing
• C. Position a communication board at the bedside
• D. Provide feeding utensils with large grip handles

Correct answer: B

Rationale: The correct intervention for a client with ALS experiencing difficulty swallowing and articulating words is to sit upright and flex the chin forward while swallowing. This position helps manage dysphagia associated with ALS by facilitating the swallowing process. Encouraging speaking slowly and articulating words (Choice A) may be helpful for speech clarity but does not address the swallowing issue. Positioning a communication board (Choice C) would not directly address the swallowing difficulty. Providing feeding utensils with large grip handles (Choice D) is not the priority intervention for managing dysphagia in ALS.

3. A young female adult wanders into the Emergency Department. She is disheveled and confused and states, 'My date must have put something in my drink. He took my car, and I think he raped me. I don't exactly remember, but I know he hurt me.' How should the nurse respond?

• A. Did you try to resist or fight back when you felt uncomfortable?
• B. He hurt you? Can you elaborate on what happened?
• C. It is okay to cry, but first, let's address your injuries and the situation.
• D. Yes, I can see. Tell me more about what you remember.

Correct answer: D

Rationale: The correct response is to encourage the patient to share more about what she remembers. This approach helps gather crucial information, supports the patient in a non-judgmental manner, and allows the nurse to provide appropriate care. Choice A has been revised to be more sensitive by asking about resistance when feeling uncomfortable rather than placing blame. Choice B has been adjusted to show empathy and request more details without questioning the patient's account. Choice C, although empathetic, does not address the immediate need to collect information and support the patient.

4. An elderly client with Alzheimer's disease is being admitted to a long-term care facility. The client’s spouse expresses concern about the level of care the client will receive. What is the most appropriate response by the nurse?

• A. Reassure the spouse that the client will be well cared for and provide information about the facility’s care practices.
• B. Inform the spouse that care will be adjusted based on the client’s condition and needs.
• C. Advise the spouse to visit frequently to monitor the quality of care the client receives.
• D. Suggest that the spouse speak with other family members for reassurance.

Correct answer: A

Rationale: The most appropriate response by the nurse in this situation is to reassure the spouse that the client will be well cared for and provide information about the facility’s care practices. This response not only addresses the spouse's concerns directly but also helps in building trust and confidence in the care provided. Choice B is not ideal as it may cause unnecessary worry about the fluctuating care levels. Choice C puts the responsibility on the spouse to monitor care, which may not always be feasible or appropriate. Choice D deflects the concern to other family members instead of addressing the spouse's worries directly.

5. A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the intravenous (IV) line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. What intervention should the nurse implement?

• A. Replace the IV site with a smaller gauge.
• B. Redress the abdominal incision.
• C. Leave the lights on in the room at night.
• D. Apply soft bilateral wrist restraints.

Correct answer: C

Rationale: The correct intervention for a client with dementia who is becoming increasingly confused at night and interfering with dressings and IV lines is to leave the lights on in the room at night. This intervention can help reduce confusion and disorientation. Choice A is incorrect because changing the IV site gauge is not the priority in this situation. Choice B is not necessary unless there are signs of infection or other complications at the abdominal incision site, which are not mentioned in the scenario. Choice D should be avoided as using restraints should be a last resort and is not indicated in this case.

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