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The nurse in charge of the labor and delivery department is making the client assignments for the day. Which client should the most experienced nurse receive?
- A. A 40-week pregnant client attached to the fetal monitor having late decelerations.
- B. A 39-week pregnant client in labor with contractions 3 minutes apart.
- C. A 33-week pregnant client with triplets who is on bed rest.
- D. A 26-week pregnant client who is having Braxton Hicks contractions.
Correct Answer: A
Rationale: Late decelerations at 40 weeks (A) indicate fetal distress, requiring the most experienced nurse for close monitoring and potential intervention. Active labor (B), preterm triplets (C), and Braxton Hicks (D) are less critical or stable, suitable for less experienced staff.
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The nurse is triaging phone calls in the prenatal clinic. The nurse should initially follow-up on the client who is
- A. 16 weeks of gestation and reports a fluttering sensation.
- B. 30 weeks of gestation and reports perianal itching and bright red blood in the stool.
- C. 28 weeks of gestation and reports intermittent leg cramping with swelling in her feet.
- D. 38 weeks of gestation and reports lower back pain that increases with walking.
Correct Answer: B
Rationale: Bright red blood in the stool at 30 weeks gestation (B) suggests possible hemorrhoids, rectal fissure, or other complications, requiring urgent follow-up to rule out serious conditions. Fluttering at 16 weeks (A) is normal quickening, leg cramps and swelling at 28 weeks (C) are common, and back pain at 38 weeks (D) is typical, all less urgent.
The nurse is reviewing the plan of care for a client admitted to the behavioral health unit with anorexia nervosa. The nurse understands that the priority goal for this client is
- A. attending scheduled group therapy.
- B. adhere to the medication regimen.
- C. gain one pound (half a kilogram) a week.
- D. demonstrate increased self-esteem.
Correct Answer: C
Rationale: Gaining one pound (half a kilogram) per week (C) is the priority goal for anorexia nervosa to address life-threatening malnutrition and stabilize physical health. Attending group therapy (A), adhering to medications (B), and improving self-esteem (D) are important but secondary to restoring nutritional status to prevent organ failure.
The client has just been given an IV dose of morphine 6 mg for neuropathic pain. A few minutes later, the nurse notes that the client's respirations are now 8, and his blood pressure has dropped from 122/83 mmHg to 88/67 mmHg. Which nursing action is the most appropriate?
- A. Prepare for intubation.
- B. Prepare to administer a dopamine infusion.
- C. Administer naloxone.
- D. Start an IV infusion of normal saline.
Correct Answer: C
Rationale: Respiratory depression (RR 8) and hypotension post-morphine (C) indicate opioid overdose, requiring naloxone to reverse effects, per ACLS guidelines. Intubation (A), dopamine (B), and saline (D) are secondary or inappropriate without reversal.
The nurse cares for an unconscious client with a dissecting aortic aneurysm that needs urgent surgery. The client's family cannot be tracked. The nurse's priority action is:
- A. Send the client to surgery.
- B. Call the hospital lawyer.
- C. Search for all the client's contacts who can provide informed consent.
- D. Notify the nursing supervisor on-call and request their permission to waive informed consent.
Correct Answer: A
Rationale: For a life-threatening dissecting aortic aneurysm requiring urgent surgery, sending the client to surgery (A) is the priority under implied consent, as delay could be fatal. Contacting a lawyer (B), searching for contacts (C), or notifying the supervisor (D) delays critical intervention.
The nurse has attended a staff education program about incident reporting. It would indicate effective understanding if the nurse states that the primary purpose of incident reporting is to
- A. implement corrective measures needed to prevent recurrence.
- B. collect data about errors and compare it to different time periods.
- C. communicate the error(s) to other departments within the facility.
- D. notify the individual involved of the deviation from the standard of care.
Correct Answer: A
Rationale: The primary purpose of incident reporting (A) is to implement corrective measures to prevent recurrence, enhancing client safety. Data collection (B), interdepartmental communication (C), and individual notification (D) are secondary benefits of the reporting process.