Nursing Elites

1. A woman is in the active phase of labor. An external monitor has been applied, and a fetal heart deceleration of uniform shape is observed, beginning just as the contraction is underway and returning to the baseline at the end of the contraction. Which of the following nursing actions is most appropriate?

• A. Administer O2.
• B. Turn the client on her left side.
• C. Notify the physician.
• D. No action is necessary

Correct answer: D

Rationale: This scenario describes early deceleration due to head compression, which is a benign finding in labor. Early decelerations mirror the contractions and do not require any intervention as they are considered a normal response to fetal head compression. The fetal heart rate returns to baseline at the end of the contraction. In this case, the correct action is no action at the moment. Close monitoring of the mother and baby is essential, but immediate intervention is not required. Administering O2 (Choice A) or turning the client on her left side (Choice B) is not indicated for early decelerations. Notifying the physician (Choice C) is unnecessary for this type of deceleration.

2. High uric acid levels can develop in clients who are receiving chemotherapy. This can be caused by:

• A. the inability of the kidneys to excrete the drug metabolites.
• B. rapid cell catabolism.
• C. toxic effects of the prophylactic antibiotics that are given concurrently.
• D. the altered blood pH from the acidic nature of the drugs.

Correct answer: B

Rationale: The correct answer is 'rapid cell catabolism.' During chemotherapy, rapid cell destruction occurs, leading to an increase in uric acid levels as a byproduct of cell breakdown. High uric acid levels are primarily a result of the rapid breakdown of cells during chemotherapy, not due to the kidneys' inability to excrete drug metabolites (Choice A). The prophylactic antibiotics given concurrently do not directly cause high uric acid levels (Choice C). The altered blood pH from the acidic nature of the drugs (Choice D) is not a direct cause of elevated uric acid levels; the main mechanism is the rapid cell catabolism that occurs during chemotherapy.

3. The nurse is checking laboratory values on a patient who has crackling rales in the lower lobes, 2+ pitting edema, and dyspnea with minimal exertion. Which of the following laboratory values does the nurse expect to be abnormal?

• A. Potassium.
• B. B-type natriuretic peptide (BNP).
• C. C-reactive protein (CRP).
• D. Platelets.

Correct answer: B

Rationale: The client's symptoms suggest heart failure. BNP is a neurohormone released from the ventricles due to increased pressure and stretch, as seen in heart failure. A BNP level greater than 51 pg/mL is often associated with mild heart failure, with higher levels indicating more severe heart failure. Potassium levels are not typically affected by heart failure. CRP is an inflammation indicator used to predict coronary artery disease risk, not directly related to heart failure in this case. The client's symptoms do not suggest bleeding or clotting abnormalities associated with platelet count issues, making platelets an unlikely abnormal value.

4. Which of the following medications is a serotonin antagonist that might be used to relieve nausea and vomiting?

• A. metoclopramide (Reglan)
• B. ondansetron (Zofran)
• C. hydroxyzine (Vistaril)
• D. prochlorperazine (Compazine)

Correct answer: B

Rationale: Zofran is a serotonin antagonist commonly used to relieve nausea and vomiting by blocking serotonin receptors. Metoclopramide (Reglan) acts on dopamine receptors, hydroxyzine (Vistaril) is an antihistamine, and prochlorperazine (Compazine) is a dopamine antagonist. While these medications can also be used for nausea and vomiting, they do not primarily function as serotonin antagonists like ondansetron.

5. While performing wound care to a donor skin graft site, the nurse notes some scabbing at the edges and a black collection of blood. What is the nurse's next action?

• A. Leave the scabbed area alone and apply extra ointment
• B. Notify the physician
• C. Gently remove the debris and re-dress the wound
• D. Apply skin softening lotion for 3 hours and then re-dress

Correct answer: C

Rationale: When the nurse notes scabbing at the edges and a black collection of blood, it indicates the presence of debris that needs to be addressed. Leaving the scabbed area alone and applying extra ointment may not address the underlying issue and could lead to complications. Notifying the physician is important in some cases, but immediate action is required to prevent infection in this situation. Gently removing the debris and re-dressing the wound is the correct course of action to promote healing and prevent complications.

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