Nursing Elites

1. A nurse is assessing a client who is in active labor, and the FHR baseline has been 100/min for 15 minutes. What should the nurse suspect?

• A. Maternal fever.
• B. Fetal anemia.
• C. Maternal hypoglycemia.
• D. Chorioamnionitis.

Correct answer: C

Rationale: The correct answer is C: Maternal hypoglycemia. Maternal hypoglycemia can lead to fetal bradycardia, which is indicated by a baseline FHR of 100/min. In this scenario, the sustained low baseline FHR suggests a possible link to maternal hypoglycemia. Maternal fever (Choice A) typically presents with tachycardia rather than bradycardia in the fetus. Fetal anemia (Choice B) usually causes fetal tachycardia as a compensatory mechanism to deliver more oxygen to tissues. Chorioamnionitis (Choice D) is associated with maternal fever and an elevated fetal heart rate, not a sustained low baseline FHR.

2. A nurse is providing discharge teaching to a client who has a new prescription for nitroglycerin sublingual tablets. Which of the following statements should the nurse include?

• A. Take the medication with food to reduce stomach upset.
• B. Store the medication in a cool, dry place.
• C. Take one tablet every 5 minutes until the pain is relieved, up to three doses.
• D. This medication may cause drowsiness.

Correct answer: C

Rationale: The correct answer is to instruct the client to take one nitroglycerin sublingual tablet every 5 minutes until the pain is relieved, up to three doses. This dosing regimen is essential for managing angina attacks effectively. Choice A is incorrect because nitroglycerin sublingual tablets should be placed under the tongue for rapid absorption, not taken with food. Choice B is incorrect because nitroglycerin tablets should be stored in their original container at room temperature, away from moisture and heat. Choice D is incorrect because nitroglycerin typically does not cause drowsiness as a side effect.

3. A nurse is assessing a client who is experiencing a panic attack. Which of the following findings should the nurse expect?

• A. Bradycardia.
• B. Hypotension.
• C. Chest pain.
• D. Dilated pupils.

Correct answer: D

Rationale: During a panic attack, the sympathetic nervous system is activated, leading to physiological responses such as dilated pupils. Bradycardia (slow heart rate) and hypotension (low blood pressure) are not typically associated with panic attacks. While chest pain can occur during a panic attack due to rapid breathing and muscle tension, dilated pupils are a more specific finding related to sympathetic activation in this context.

4. A client has a new prescription for ferrous sulfate. Which of the following instructions should the nurse include in the teaching?

• A. Take this medication on an empty stomach.
• B. Take this medication with milk if it causes stomach upset.
• C. Take this medication with orange juice to increase absorption.
• D. Take an antacid 1 hour after this medication.

Correct answer: C

Rationale: The correct instruction is to take ferrous sulfate with orange juice to increase absorption because the vitamin C content in orange juice enhances iron absorption. Choice A is incorrect because ferrous sulfate should be taken with food to reduce gastrointestinal side effects. Choice B is incorrect because milk can decrease iron absorption. Choice D is incorrect because antacids can reduce the absorption of ferrous sulfate.

5. What is the appropriate action when a patient presents with chest pain?

• A. Administer aspirin
• B. Administer nitroglycerin
• C. Reposition the patient
• D. Prepare for surgery

Correct answer: A

Rationale: The appropriate action when a patient presents with chest pain is to administer aspirin. Aspirin helps reduce the risk of clot formation by inhibiting platelet aggregation, which can be beneficial in cases of myocardial infarction. Nitroglycerin is commonly used for chest pain related to angina but is not the first-line treatment for all types of chest pain. Repositioning the patient may be necessary for comfort or assessment but is not the immediate priority. Surgery is not typically the first-line intervention for chest pain unless there are specific indications.

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