Nursing Elites

1. The nurse is assessing a client who has a new cast on the left arm. Which finding should the nurse report to the healthcare provider immediately?

• A. Client reports itching under the cast
• B. Client reports pain at the cast site
• C. Client reports swelling of the fingers
• D. Client reports warmth over the casted area

Correct answer: C

Rationale: Swelling of the fingers can indicate compromised circulation, which is a serious concern in a client with a new cast. It could suggest the development of compartment syndrome, a condition where increased pressure within the muscles can lead to impaired blood flow. This can result in tissue damage and should be addressed promptly. Itching under the cast, pain at the cast site, and warmth over the casted area are common findings after cast application and may not necessarily indicate an urgent issue requiring immediate reporting to the healthcare provider.

2. A client who has had three spontaneous abortions is requesting information about possible causes. The nurse's response should be based on which information?

• A. Chromosomal abnormalities are the most common cause of early spontaneous abortions
• B. Incompetent cervix can cause spontaneous abortions
• C. An infection can cause spontaneous abortions
• D. Nutritional deficiencies are the most common cause of early spontaneous abortions

Correct answer: A

Rationale: The correct answer is A: Chromosomal abnormalities are the most common cause of early spontaneous abortions. Spontaneous abortions, also known as miscarriages, often occur due to chromosomal abnormalities in the fetus. These abnormalities are a common cause of early pregnancy loss. Choice B is incorrect because an incompetent cervix typically leads to late miscarriages, not early spontaneous abortions. Choice C is incorrect as while infections can be a cause of spontaneous abortions, they are not the most common cause. Choice D is incorrect as nutritional deficiencies are not the most common cause of early spontaneous abortions.

3. When caring for a laboring client whose contractions are occurring every 2 to 3 min, the nurse should document that the pump is infusing how many ml/hr?

• A. 42
• B. 50
• C. 60
• D. 70

Correct answer: A

Rationale: To calculate the infusion rate, we first need to determine the frequency of contractions per hour. If contractions are occurring every 2 to 3 minutes, this corresponds to 20 to 30 contractions in an hour (60 minutes). The average is 25 contractions in an hour. The pump should be infusing 1 ml for each contraction, so the infusion rate should be 25 ml/hr. Therefore, the correct answer is 42 ml/hr. Choices B, C, and D are incorrect as they do not align with the calculation based on the given data.

4. A client with a C-6 spinal injury changes to a breathing pattern of shallow respirations and dyspnea twelve hours after the causative incident. The nurse should notify the healthcare provider and implement which intervention?

• A. Place the client in reverse Trendelenburg position
• B. Prepare for intubation with an endotracheal tube
• C. Administer a pain medication to the client
• D. Instruct the client on deep breathing exercises

Correct answer: B

Rationale: In a client with a C-6 spinal injury exhibiting shallow respirations and dyspnea, these signs could indicate respiratory compromise and potential respiratory failure. Intubation with an endotracheal tube may be necessary to secure the airway and support adequate oxygenation. Placing the client in reverse Trendelenburg position, administering pain medication, or instructing on deep breathing exercises would not directly address the urgency of the respiratory distress in this situation, making them incorrect choices.

5. When caring for a laboring client whose contractions are occurring every 2-3 minutes, the nurse should document that the pump is infusing how many ml/hour?

• A. 5
• B. 10
• C. 15
• D. 20

Correct answer: A

Rationale: The correct calculation for infusion based on the given data is 5 ml/hr. To calculate the infusion rate per hour, you need to determine the number of contractions per hour. If contractions are occurring every 2-3 minutes, this would mean approximately 20-30 contractions per hour. Therefore, if the pump is infusing 5 ml per contraction, the total infusion rate per hour would be 5 ml x 20 contractions = 100 ml/hr. This makes choice A the correct answer. Choices B, C, and D are incorrect as they do not align with the calculation based on the given data.

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