Nursing Elites

1. While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse's first action?

• A. Check vital signs.
• B. Massage the fundus.
• C. Offer a bedpan.
• D. Check for perineal lacerations.

Correct answer: B

Rationale: The nurse's first action should be to massage the fundus until it is firm as uterine atony is the primary cause of bleeding in the first hour after delivery. Massaging the fundus helps to stimulate uterine contractions, which can help control the bleeding. Checking vital signs would be important but addressing the primary cause of bleeding takes precedence. Offering a bedpan is not a priority in this situation as the focus should be on managing the postpartum bleeding. Checking for perineal lacerations is also important but not the initial action needed to address the boggy uterus and vaginal bleeding.

2. The nurse is caring for a client in the late stages of Amyotrophic Lateral Sclerosis (A.L.S.). Which finding would the nurse expect?

• A. Confusion
• B. Loss of half of the visual field
• C. Shallow respirations
• D. Tonic-clonic seizures

Correct answer: C

Rationale: In the late stages of Amyotrophic Lateral Sclerosis (A.L.S.), respiratory muscles are affected, leading to shallow respirations. Confusion is not typically associated with A.L.S. Loss of half of the visual field suggests a neurological issue unrelated to A.L.S., while tonic-clonic seizures are not commonly seen in A.L.S. patients. Shallow respirations are a hallmark sign of respiratory muscle weakness in A.L.S. due to the degeneration of motor neurons.

3. The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is:

• A. Verify correct placement of the tube
• B. Check that the feeding solution matches the dietary order
• C. Aspirate gastric contents to determine the amount of the last feeding remaining in the stomach
• D. Ensure that the feeding solution is at room temperature

Correct answer: A

Rationale: The most crucial action for the nurse when preparing to administer enteral feeding via a nasogastric tube is to verify the correct placement of the tube. Proper placement of the tube is vital to prevent complications such as aspiration into the lungs. The definitive methods to confirm the position of the nasogastric tube include visualization through an x-ray or aspirating stomach contents and checking their pH (usually pH 1 to 5). Aspirated stomach content can also be tested for bilirubin to confirm placement in the stomach. Choice B, checking that the feeding solution matches the dietary order, is important for ensuring the correct nutrition is provided but is not as critical as verifying tube placement to prevent potential harm. Choice C, aspirating gastric contents to determine the amount of the last feeding remaining in the stomach, is a common nursing practice but is not the most crucial action when compared to ensuring correct tube placement. Choice D, ensuring that the feeding solution is at room temperature, is relevant for patient comfort and preventing thermal injury but is not as essential as confirming correct tube placement to prevent serious complications.

4. Why are subdural hemorrhages more common in the elderly?

• A. Increased anticoagulant use
• B. Increased risk of falls
• C. Brain atrophy
• D. Inconsistent care giving

Correct answer: C

Rationale: Subdural hemorrhages are more common in the elderly due to cerebral atrophy resulting from the natural aging process. This atrophy can lead to the stretching of bridging veins, making them more fragile and prone to tearing even with minor trauma. While increased anticoagulant use and a higher risk of falls are common in the elderly, brain atrophy plays a more direct role in the increased incidence of subdural hemorrhages. Inconsistent caregiving, on the other hand, is not a direct cause of subdural hemorrhages but may impact the overall management and outcome of such cases.

5. The healthcare provider is caring for a 20 lbs (9 kg) 6-month-old with a 3-day history of diarrhea, occasional vomiting, and fever. Peripheral intravenous therapy has been initiated, with 5% dextrose in 0.33% normal saline with 20 mEq of potassium per liter infusing at 35 ml/hr. Which finding should be reported to the healthcare provider immediately?

• A. 3 episodes of vomiting in 1 hour
• B. Periodic crying and irritability
• C. Vigorous sucking on a pacifier
• D. No measurable voiding in 4 hours

Correct answer: D

Rationale: The correct answer is 'No measurable voiding in 4 hours.' This finding should be reported to the healthcare provider immediately. The concern is the possibility of hyperkalemia, which could occur with continued potassium administration and a decrease in urinary output since potassium is excreted via the kidneys. It is crucial to monitor urinary output in pediatric patients receiving potassium-containing IV solutions to prevent electrolyte imbalances and potential complications. Choices A, B, and C are not the most critical findings that require immediate reporting. '3 episodes of vomiting in 1 hour' may suggest a need for antiemetic therapy or further assessment of the underlying cause but does not pose an immediate risk like the potential electrolyte imbalance from decreased urinary output. 'Periodic crying and irritability' and 'Vigorous sucking on a pacifier' are common behaviors in infants and are not indicative of a critical condition that requires urgent attention in this scenario.

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