Nursing Elites

1. The client is undergoing an induction for fetal demise at 34 weeks. Immediately after delivery, the mother asks to see the infant. What is the nurse's best response?

• A. Bring the swaddled fetus to the mother
• B. Explain that the cause of death must be determined before she can see the baby
• C. Ask her if she is sure she wants to see the baby
• D. Tell her it would be better to wait until she is in her room before she sees the baby

Correct answer: A

Rationale: The nurse should bring the swaddled fetus to the mother as the best response. Allowing the mother to see the infant immediately after delivery is crucial for her grieving process. It provides her with the opportunity to bond, say goodbye, and start the grieving process. Choice B is incorrect because delaying the mother's request to see the baby can hinder her grieving process and prolong her suffering. Choice C is inappropriate as it questions the mother's decision at a sensitive time, potentially causing distress. Choice D is also not the best response as it suggests waiting, which may not be in the mother's best interest at that moment, as she needs immediate support and closure.

2. A client with asthma develops respiratory acidosis. Based on this diagnosis, what should the nurse expect the client's serum potassium level to be?

• A. normal
• B. elevated
• C. low
• D. unrelated to the pH

Correct answer: B

Rationale: In respiratory acidosis, the body retains CO2, leading to increased hydrogen ion concentration and a drop in blood pH. As pH decreases, serum potassium levels increase due to the movement of potassium out of cells to compensate for the acidosis. Elevated serum potassium levels are expected in respiratory acidosis. Choice A ('normal') is incorrect because potassium levels are expected to be elevated in respiratory acidosis. Choice C ('low') is incorrect as potassium levels rise in this condition. Choice D ('unrelated to the pH') is incorrect as serum potassium levels are directly impacted by changes in pH in respiratory acidosis.

3. Which of the following should not be included in the teaching for clients who take oral iron preparations?

• A. Mix the liquid iron preparation with antacids to reduce GI distress.
• B. Take the iron with meals if GI distress occurs.
• C. Liquid forms should be taken with a straw to avoid discoloration of tooth enamel.
• D. Oral forms should be taken with juice, not milk.

Correct answer: A

Rationale: The correct answer is to mix the liquid iron preparation with antacids to reduce GI distress. This statement is incorrect because iron should not be mixed with antacids as it can significantly reduce the absorption of iron. Choice B is a good recommendation as taking iron with meals can help reduce gastrointestinal distress. Choice C is also correct as liquid forms of iron should be taken with a straw to prevent the discoloration of tooth enamel. Choice D is incorrect as iron preparations can be taken with juice or water, but not with milk, as calcium in milk can inhibit iron absorption.

4. A client has been diagnosed with Disseminated Intravascular Coagulation (DIC) and transferred to the medical intensive care unit (ICU) following an acute bleeding episode. In the ICU, continuous Heparin drip therapy is initiated. Which of the following assessment findings indicates a positive response to Heparin therapy?

• A. increased platelet count
• B. increased fibrinogen
• C. decreased fibrin split products
• D. decreased bleeding

Correct answer: B

Rationale: In the context of DIC, effective Heparin therapy aims to halt the process of intravascular coagulation. One of the indicators of a positive response to Heparin therapy is an increase in fibrinogen levels. Heparin interferes with the conversion of fibrinogen to fibrin by thrombin. This interruption helps increase the availability of fibrinogen. While the platelet count may increase due to improved clotting, the primary focus of Heparin therapy is on fibrinogen. Fibrin split products are expected to decrease as the coagulation cascade is controlled. Although decreased bleeding is an ultimate goal, the immediate effect of Heparin is not directly on bleeding but on the coagulation process.

5. The nurse is caring for a client with decreased cardiac output secondary to heart failure with fluid volume overload. The effects of diminished renal perfusion will have which physiologic response?

• A. Diuresis
• B. Increased fluid retention
• C. Elevated bicarbonate level
• D. Paroxysmal idiopathic narcosis

Correct answer: B

Rationale: When there is diminished renal perfusion due to decreased cardiac output, the kidneys receive less blood flow. This leads to a decrease in urine output and an increase in fluid retention, as the kidneys are not able to effectively filter and excrete excess fluid. Elevated bicarbonate level and paroxysmal idiopathic narcosis are not typically associated with diminished renal perfusion in heart failure. Therefore, the correct answer is 'Increased fluid retention.'

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