Nursing Elites

1. The nurse is caring for a laboring 22-year-old primigravida following administration of regional anesthesia. In planning care for this client, what nursing intervention has the highest priority?

• A. Raising the side rails and placing the call bell within reach
• B. Teaching the client how to push effectively to decrease the length of the second stage of labor
• C. Timing and recording uterine contractions
• D. Positioning the client for proper distribution of anesthesia

Correct answer: A

Rationale: The highest priority nursing intervention for a laboring client following administration of regional anesthesia is to ensure safety by raising the side rails and placing the call bell within reach. This is crucial to prevent falls and to ensure that the client can call for assistance if needed. Teaching the client how to push effectively (Choice B) is important but not the highest priority at this moment. Timing and recording uterine contractions (Choice C) are essential but not as immediate as ensuring safety post-anesthesia. Positioning the client for proper distribution of anesthesia (Choice D) is important but ensuring immediate safety takes precedence in this situation.

2. A 20-year-old female client tells the nurse that her menstrual periods occur about every 28 days, and her breasts are quite tender when her menstrual flow is heavy. She also states that she performs her breast self-examination (BSE) on the first day of every month. What action should the nurse implement in response to the client's statements?

• A. Remind the client that it is also important to schedule an annual mammogram
• B. Refer the client to a nurse practitioner for an in-depth review of the BSE procedure
• C. Encourage the client to perform BSE 2 to 3 days after the menstrual period ends
• D. Instruct the client to continue with her regular monthly exams as she is doing

Correct answer: C

Rationale: The correct response is to encourage the client to perform breast self-examination (BSE) 2 to 3 days after her menstrual period ends. This timing is important because breasts are least tender during this phase of the menstrual cycle, allowing for a more effective examination. Choice A is incorrect because while scheduling an annual mammogram is important, the immediate concern is the timing of BSE. Choice B is incorrect as the client's BSE practice just needs a slight adjustment in timing, not an in-depth review. Choice D is incorrect as the client should perform BSE when her breasts are least tender for optimal detection of any abnormalities.

3. A nurse is preparing to administer an intramuscular injection to a client. Which action should the nurse take to reduce the client's risk of injury?

• A. Use a 1-inch needle
• B. Select a large muscle for the injection
• C. Aspirate for blood return before injecting
• D. Massage the injection site

Correct answer: C

Rationale: The correct answer is to aspirate for blood return before injecting. This action helps ensure that the needle is not in a blood vessel, reducing the risk of injury. Using a 1-inch needle (Choice A) is a standard length for intramuscular injections but does not directly reduce the risk of injury. Selecting a large muscle for the injection (Choice B) is important for proper medication absorption but does not directly reduce the risk of injury. Massaging the injection site (Choice D) can help with medication absorption but does not reduce the risk of injury.

4. The nurse is assessing on the first postoperative day following thyroid surgery. Which laboratory value is most important for the nurse to monitor?

• A. Calcium
• B. Sodium
• C. Chloride
• D. Potassium

Correct answer: A

Rationale: Corrected Rationale: Monitoring calcium levels is crucial post-thyroid surgery to detect hypocalcemia, a common complication due to injury or removal of the parathyroid glands. Monitoring sodium, chloride, or potassium levels is not as vital in the immediate post-thyroid surgery period.

5. A client who is gravida 1, para 0, is admitted to the birthing suite in early labor and requests pain relief. Which action should the nurse implement?

• A. Encourage the client to use distraction techniques
• B. Offer to teach the client relaxation techniques
• C. Determine the client’s pain level and location
• D. Administer an opioid analgesic as prescribed

Correct answer: D

Rationale: In this scenario, the correct action for the nurse to implement is to administer an opioid analgesic as prescribed. Since the client is in early labor and requesting pain relief, opioids are commonly used to provide effective pain relief during labor. Encouraging distraction or teaching relaxation techniques may not be sufficient for pain management during labor, especially in the early stages when the pain intensity can increase rapidly. Determining the pain level and location is important but administering the prescribed opioid is the most appropriate action to address the client's request for pain relief.

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