Nursing Elites

1. A client is in active labor and is receiving an epidural for pain relief. Which of the following should the nurse monitor as the priority?

• A. Fetal heart rate
• B. Client's blood pressure
• C. Client's respiratory rate
• D. Client's pain level

Correct answer: B

Rationale: The most common side effect of an epidural is hypotension, which can compromise placental perfusion. Monitoring the client's blood pressure is the priority to ensure maternal and fetal well-being. Fetal heart rate is important but monitoring the client's blood pressure takes precedence due to the risk of hypotension. Respiratory rate and pain level monitoring are also important but not the priority in this scenario.

2. A nurse is providing teaching to a client who is scheduled for electromyography (EMG). Which of the following information should the nurse include in the teaching?

• A. “You will receive a fixed dose of radioisotope 2 hours before the procedure.”
• B. “Momentary flushing may occur at the beginning of the procedure.”
• C. “You should inform your provider if you are claustrophobic.”
• D. “You should expect insertion of small needle electrodes into the muscles.”

Correct answer: D

Rationale: The correct answer is D. During an electromyography (EMG) procedure, small needle electrodes are inserted into the muscles to identify muscle weakness and evaluate local nerve responses. This information is crucial for the client to know beforehand. Choice A is incorrect because radioisotopes are not used in EMG procedures. Choice B is incorrect because flushing is not a common occurrence during EMG. Choice C is incorrect because claustrophobia is more relevant to MRI or CT scans, not EMG procedures.

3. A nurse is monitoring a client who has been receiving intermittent enteral feedings. What should the nurse identify as an intolerance to the feeding?

• A. Increased appetite
• B. Nausea
• C. Weight gain
• D. Regular bowel movements

Correct answer: B

Rationale: Nausea is a common sign of intolerance to enteral feedings. When a client experiences nausea, it can indicate difficulty in tolerating the feeding formula. This intolerance may also manifest as vomiting and dumping syndrome. Choices A, C, and D are incorrect because increased appetite, weight gain, and regular bowel movements are not typical signs of intolerance to enteral feedings.

4. A nurse has been caring for a female client who has bruises on her arms that she explains are a result of physical abuse by her husband. The client states, “I don’t know how much longer I can take this, but I’m afraid he’ll really hurt me if I leave.” Which of the following is an appropriate nursing intervention?

• A. Offer to speak to the client’s husband regarding his abusive behavior
• B. Help the client to recognize signs of escalation in abusive behavior
• C. Assist the client in identifying personal behaviors that trigger abuse
• D. Assist the client in reporting the abusive behavior to authorities

Correct answer: D

Rationale: Assisting the client in reporting the abuse is a critical step in ensuring her safety and initiating legal action to protect her from further harm. Option A is inappropriate as it may escalate the situation and put the client at further risk. Option B focuses on the client recognizing signs of abuse, which is not as urgent as reporting it to authorities. Option C places the responsibility on the client for triggering the abuse, which is victim-blaming and not helpful in this context.

5. While caring for a client in active labor, a nurse notes late decelerations in the FHR on the external fetal monitor. Which of the following actions should the nurse take first?

• A. Change the client's position
• B. Palpate the uterus to assess for tachysystole
• C. Increase the client's IV infusion rate
• D. Administer oxygen at 10 L/min via nonrebreather mask

Correct answer: A

Rationale: The correct initial action for the nurse to take is to change the client's position. This intervention can alleviate pressure on the umbilical cord, potentially improving fetal oxygenation and addressing the underlying cause of late decelerations. Palpating the uterus to assess for tachysystole or increasing the IV infusion rate are not the first-line interventions for addressing late decelerations. Administering oxygen at a high flow rate via a nonrebreather mask may be necessary but is not the priority action in this situation.

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