Nursing Elites

1. The nurse assesses a client’s wound. What type of wound requires immediate intervention by the nurse?

• A. Laceration
• B. Abrasion
• C. Contusion
• D. Ulceration

Correct answer: A

Rationale: Lacerations, especially deep ones, are prone to bacterial contamination and may require immediate intervention to prevent infection. Abrasions, contusions, and ulcerations are not as likely to lead to immediate serious complications like infections as lacerations.

2. When assessing a recently delivered multigravida client, the nurse finds that her vaginal bleeding is more than expected. Which factor in this client's history is related to this finding?

• A. The client delivered a large baby
• B. She is a gravida 6, para 5
• C. The client had a cesarean delivery
• D. The client had a prolonged labor

Correct answer: B

Rationale: A client with a higher gravida and para count is at greater risk for uterine atony, which can lead to postpartum hemorrhage. The uterus may be less effective at contracting after multiple pregnancies, causing increased vaginal bleeding. Choices A, C, and D are incorrect because delivering a large baby, having a cesarean delivery, or experiencing prolonged labor do not directly correlate with an increased risk of postpartum hemorrhage in a multigravida client as compared to the gravida and para count.

3. A client with anxiety disorder is experiencing increased anxiety prior to vaginal delivery. What should the nurse’s initial action be?

• A. Increase the client's sedative dose
• B. Encourage the client to express her feelings and provide emotional support
• C. Initiate breathing techniques to manage anxiety
• D. Administer anxiolytic medication to calm the client

Correct answer: B

Rationale: The correct initial action for a client with anxiety disorder experiencing increased anxiety prior to vaginal delivery is to encourage the client to express her feelings and provide emotional support. Emotional support is crucial in reducing anxiety during childbirth. Initiating breathing techniques or administering medications should come after emotional support has been provided. Increasing sedative doses may not address the underlying emotional needs of the client and can have potential risks.

4. A 5-week-old infant who developed projectile vomiting over the last two weeks is diagnosed with hypertrophic pyloric stenosis. Which intervention should the nurse plan to implement?

• A. Instruct the mother to give the child sugar water only.
• B. Offer oral rehydration solution every 2 hours.
• C. Provide Pedialyte feedings via nasogastric tube.
• D. Maintain intravenous fluid therapy per prescription.

Correct answer: D

Rationale: The correct intervention for a 5-week-old infant diagnosed with hypertrophic pyloric stenosis and experiencing projectile vomiting is to maintain intravenous fluid therapy. Intravenous fluids are crucial for rehydrating an infant suffering from dehydration due to rapid fluid loss from vomiting. Instructing the mother to provide sugar water only (choice A) is inappropriate and insufficient for rehydration. Offering oral rehydration solution every 2 hours (choice B) may not be effective if the infant continues to vomit. Providing Pedialyte feedings via nasogastric tube (choice C) may also not be as effective as intravenous fluid therapy in rapidly replenishing fluids and stabilizing the child's condition.

5. An older adult client with eye dryness reports itching and excessive tearing. Which medication group is most likely to have produced this client's symptoms?

• A. Antiinfectives and antidepressants.
• B. Anticoagulants and antihistamines.
• C. Antiretrovirals and antivirals.
• D. Antihypertensives and anticholinergics.

Correct answer: D

Rationale: The correct answer is D: Antihypertensives and anticholinergics. Anticholinergics are known to cause dryness of secretions, including dry eyes, which can lead to symptoms of eye dryness, itching, and excessive tearing as reported by the client. Choices A, B, and C are incorrect as they do not typically cause the symptoms described by the client. Antiinfectives, antidepressants, anticoagulants, antihistamines, antiretrovirals, and antivirals do not commonly lead to dry eyes, itching, and excessive tearing.

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