Nursing Elites

1. How does the family carry out its health care functions?

• A. The family provides very little preventive health care to its members at home.
• B. The family provides preventive health care to its members at home.
• C. The family pays for most health services.
• D. The family decides when and where to hospitalize its members.

Correct answer: B

Rationale: Families play a crucial role in providing preventive health care to their members at home. This includes activities such as promoting healthy lifestyles, ensuring vaccinations, scheduling regular check-ups, and intervening early when health issues arise. Therefore, the correct answer is that the family provides preventive health care to its members at home. Choices A, C, and D are incorrect because families are expected to actively engage in preventive health care practices rather than providing very little preventive care, solely paying for health services, or making hospitalization decisions. The focus is on the proactive role of families in maintaining the health of their members.

2. When a woman is receiving postpartum epidural morphine, the nurse should plan to observe for which of the following side effects to occur within the first 3 hours?

• A. nausea and vomiting
• B. itching
• C. urinary retention
• D. somnolence

Correct answer: B

Rationale: A side effect of postpartum epidural morphine is the onset of itching within 3 hours of injection and lasting up to 10 hours. Nausea and vomiting might occur 4-7 hours after injection. While urinary retention is a side effect of postpartum epidural morphine, it is not typically assessed within the first 3 hours. Somnolence is a rare side effect and not commonly observed within the first 3 hours. Therefore, itching is the most likely side effect to be observed within the initial 3 hours after administering postpartum epidural morphine.

3. A client complains that her skin is redder than normal. The nurse notes the client's skin, documents hyperemia, and explains to the client that this condition is caused by which factor?

• A. Constriction of the underlying blood vessels
• B. An increased amount of bilirubin in the blood
• C. Increased perfusion of the surrounding tissues
• D. Excess blood in the dilated superficial capillaries

Correct answer: D

Rationale: Hyperemia is an excess of blood in a part of the body. The skin over a hyperemic area usually becomes reddened or warm. The condition is caused by increased blood flow, local relaxation of arterioles, or obstruction of the outflow of blood from an area. Choice A is incorrect because constriction of blood vessels would lead to decreased blood flow, not excess blood. Choice B is incorrect as an increased amount of bilirubin in the blood is related to jaundice, not hyperemia. Choice C is incorrect because increased perfusion of the surrounding tissues would cause redness, not hyperemia.

4. After delivering a healthy newborn 1 hour ago, a nurse notes a woman's radial pulse rate is 55 beats/min. What action should the nurse take based on this finding?

• A. Reporting the finding to the healthcare provider immediately
• B. Helping the woman stay in bed and rest
• C. Documenting the finding
• D. Performing active and passive range-of-motion exercises

Correct answer: C

Rationale: After delivery, bradycardia (pulse rate 50-70 beats/min) may occur, reflecting the large amount of blood returning to the central circulation after delivery of the placenta. The increase in central circulation results in increased stroke volume, allowing a slower heart rate to provide adequate maternal circulation. A pulse rate of 55 beats/min falls within the normal range post-delivery, so there is no need to notify the healthcare provider immediately. It is important for the client to remain on bed rest in the immediate postpartum period to prevent complications. While range-of-motion exercises are beneficial for a client on bed rest, it is not the priority based on the data provided. Therefore, the most appropriate nursing action is to document the finding for accurate record-keeping and monitoring of the client's condition.

5. A client with massive chest and head injuries is admitted to the ICU from the Emergency Department. All of the following are true except:

• A. The physician in charge of the case is the sole person allowed to decide whether organ donation can occur.
• B. The client's legally responsible party may make the decision for organ donation for the donor if the client is unable to do so.
• C. The organ procurement organization makes the decision regarding which organs to harvest.
• D. The donor (or legally responsible party for the donor), the physician, and the organ-procurement organization are all involved in the process.

Correct answer: A

Rationale: While the physician plays a crucial role in the process of organ donation, they are not the sole decision-maker. The client's legally responsible party may make the decision for organ donation if the client is unable to do so. Additionally, the organ procurement organization is responsible for determining which organs are suitable for donation. Therefore, the statement that the physician in charge is the sole person allowed to decide whether organ donation can occur is incorrect. The correct answer is A. Choices B, C, and D are true statements as they highlight the involvement of the legally responsible party, the organ procurement organization, and the donor/legally responsible party, physician, and organ-procurement organization in the organ donation process respectively.

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