Nursing Elites

1. During a routine prenatal visit at the antepartal clinic, a multipara at 35-weeks gestation presents with 2+ edema of the ankles and feet. Which additional information should the PN report to the RN?

• A. Due date
• B. Blood pressure
• C. Gravida and parity
• D. Fundal height

Correct answer: B

Rationale: Blood pressure is the most critical information to report to the RN in this scenario. The presence of edema, along with high blood pressure, can be indicative of preeclampsia, a severe condition in pregnancy. Monitoring blood pressure is essential for assessing the patient's condition and taking appropriate actions if necessary. Choices A, C, and D are not as urgent in this situation. The due date, gravida, and parity are important for overall assessment but do not address the immediate concern of potential preeclampsia. Fundal height is used to assess fetal growth and position but is not the priority when edema and high blood pressure are present.

2. An adult client is undergoing weekly external radiation treatments for breast cancer. Upon arrival at the outpatient clinic for a scheduled treatment, the client reports increasing fatigue to the nurse who is taking the client's vital signs. What action should the nurse implement?

• A. Notify the healthcare provider or charge nurse immediately
• B. Offer to reschedule the treatment for the following week
• C. Plan to monitor the client's vital signs every 30 minutes
• D. Reinforce the need for extra rest periods and plenty of sleep

Correct answer: D

Rationale: Fatigue is a common side effect of radiation therapy. In this scenario, the appropriate action for the nurse to take is to reinforce the importance of rest and adequate sleep. It is crucial to address the client's increasing fatigue by promoting self-care strategies such as additional rest periods and ensuring plenty of sleep. Rescheduling the treatment is not necessary for fatigue, and vital sign monitoring every 30 minutes may not directly address the client's reported symptom. Notifying the healthcare provider or charge nurse immediately is not the first-line intervention for increasing fatigue, as this symptom can be managed through education and self-care recommendations.

3. A nurse is caring for a 60-year-old man who is scheduled to have coronary bypass surgery in the morning. He tells the nurse that he is afraid that he will die and he is scared of the surgery. What is the best reply for this nurse to give him?

• A. There is no reason to be scared. My father had this surgery, and now he’s playing tennis with his friends almost every day.
• B. I would be scared too. It’s a natural thing to feel. Don’t worry. Everything will be alright.
• C. You’re scared?
• D. The doctor has performed hundreds of successful bypass surgeries. I have a lot of faith in him.

Correct answer: C

Rationale: The best reply for the nurse to give the patient is option C: 'You’re scared?' This response reflects empathy and understanding, acknowledging the patient's feelings of fear. By directly addressing the patient's emotions, the nurse encourages further expression of concerns, which is crucial in providing emotional support. Choices A and D may come off as dismissive of the patient's feelings by downplaying his fear or shifting the focus to others' experiences. Choice B, although acknowledging the patient's fear, does not actively engage with the patient's emotions or encourage further discussion.

4. When administering an analgesic to a client with low back pain, which intervention should the practical nurse implement to promote the effectiveness of the medication?

• A. Massage the lower back and position the client in proper alignment
• B. Encourage the client to ambulate frequently and take deep breaths
• C. Assist the client in performing passive and active range of motion exercises
• D. Give medication with a full glass of water and offer high-fiber foods

Correct answer: A

Rationale: Massaging the lower back and positioning the client in proper alignment can help relieve muscle tension and enhance the effectiveness of analgesics by providing additional comfort and promoting better pain management. This intervention directly addresses the site of pain and can improve the medication's efficacy. Choices B, C, and D are incorrect because while they may have benefits in other situations, they are not directly related to promoting the effectiveness of analgesics in clients with low back pain. Encouraging ambulation and deep breathing, assisting with range of motion exercises, and offering water and high-fiber foods are important for overall patient care but are not specific to enhancing analgesic effectiveness in this context.

5. When preparing to administer a medication through a nasogastric (NG) tube, what is the first action the nurse should take?

• A. Check the placement of the NG tube
• B. Flush the tube with saline
• C. Position the client in a semi-Fowler's position
• D. Administer the medication slowly

Correct answer: A

Rationale: The correct first action when preparing to administer a medication through a nasogastric (NG) tube is to check the placement of the NG tube. This step is essential to ensure that the tube is correctly positioned in the stomach and not in the lungs, preventing potential complications. Flushing the tube with saline may be required, but it should follow the verification of tube placement. Positioning the client in a semi-Fowler's position is necessary for comfort during the procedure but is not the initial step. Administering the medication can only be done safely after confirming the correct placement of the NG tube.

Similar Questions