Nursing Elites

1. A client in labor is experiencing late decelerations in fetal heart rate. What intervention should the nurse perform first?

• A. Reposition the client onto her left side.
• B. Apply oxygen via nasal cannula.
• C. Prepare for an emergency cesarean section.
• D. Increase IV fluid administration to improve perfusion.

Correct answer: A

Rationale: Late decelerations indicate fetal distress due to compromised placental perfusion. Repositioning the client onto her left side is the priority intervention as it can increase blood flow to the placenta, improving fetal oxygenation. Applying oxygen via nasal cannula (choice B) can be the next step after repositioning if late decelerations persist. Emergency cesarean section (choice C) is not the initial action for late decelerations unless other interventions are ineffective. Increasing IV fluid administration (choice D) is not the first-line intervention for late decelerations; repositioning takes precedence to address the underlying cause.

2. The nurse is planning care for a client with a venous leg ulcer. Which intervention should the nurse include in the plan of care to promote healing?

• A. Apply compression therapy to the affected leg
• B. Keep the affected leg in a dependent position
• C. Massage the area surrounding the ulcer
• D. Encourage the client to elevate the leg for 2 hours daily

Correct answer: A

Rationale: Compression therapy is essential for managing venous leg ulcers as it helps improve venous return, reduces edema, and promotes healing. By applying compression therapy to the affected leg, the nurse can assist in enhancing circulation, reducing swelling, and aiding in the healing process. Keeping the affected leg in a dependent position can worsen venous insufficiency. Massaging the area surrounding the ulcer is contraindicated as it can cause further damage and delay healing. While encouraging the client to elevate the leg is beneficial, it is not as effective as compression therapy for promoting healing in venous leg ulcers.

3. A client with adrenal crisis has a temperature of 102°F, heart rate of 138 bpm, and blood pressure of 80/60 mmHg. Which action should the nurse implement first?

• A. Obtain an analgesic prescription.
• B. Infuse intravenous fluid bolus.
• C. Administer PRN oral antipyretic.
• D. Cover the client with a cooling blanket.

Correct answer: B

Rationale: In a client with adrenal crisis presenting with a high temperature, tachycardia, and hypotension, the priority action for the nurse to implement first is to infuse an intravenous fluid bolus. This intervention aims to address the hypotension by increasing the circulating volume and improving perfusion. Obtaining an analgesic prescription (Choice A) is not the priority in this situation. Administering an oral antipyretic (Choice C) may help reduce the fever but does not address the primary issue of hypotension. Covering the client with a cooling blanket (Choice D) may help with temperature control but does not address the hemodynamic instability caused by the adrenal crisis.

4. A client with diabetes mellitus is scheduled for surgery. What is the nurse's priority action when preparing this client for surgery?

• A. Ensure the client is NPO before surgery
• B. Monitor the client's blood glucose levels
• C. Administer the client's insulin as scheduled
• D. Teach the client about postoperative care

Correct answer: B

Rationale: The correct answer is B: Monitor the client's blood glucose levels. Clients with diabetes are at risk for perioperative complications related to blood glucose fluctuations. Monitoring blood glucose levels is crucial to maintaining proper management before, during, and after surgery. Option A is not the priority action as ensuring NPO status is a standard preoperative procedure for all clients. Option C could be important but is secondary to monitoring blood glucose levels. Option D is important but not the priority during the preoperative phase.

5. The nurse is caring for a client with an indwelling urinary catheter. Which of the following actions should the nurse prioritize to prevent infection?

• A. Maintain a closed drainage system
• B. Cleanse the catheter insertion site daily
• C. Increase the client's fluid intake
• D. Empty the collection bag every 4 hours

Correct answer: A

Rationale: The correct answer is to maintain a closed drainage system. This action is crucial in preventing infection as it helps prevent bacteria from entering the urinary tract. While cleansing the catheter insertion site and ensuring adequate hydration are important aspects of catheter care, the top priority is maintaining the integrity of the closed system to prevent infection. Emptying the collection bag regularly is also important but not as critical as ensuring a closed drainage system to minimize infection risk.

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