Nursing Elites

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

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

Correct answer: C

Rationale: In this scenario, the FHR baseline of 100/min for the past 15 minutes indicates fetal bradycardia, which can be caused by maternal hypoglycemia. Maternal hypoglycemia can lead to decreased oxygen supply to the fetus, resulting in fetal bradycardia. Maternal fever (Choice A) typically presents with tachycardia in the fetus rather than bradycardia. Fetal anemia (Choice B) is more likely to manifest as tachycardia due to compensation for decreased oxygen delivery. Chorioamnionitis (Choice D) may lead to fetal tachycardia as a sign of fetal distress, not bradycardia.

2. A nurse is caring for a client who has Raynaud's disease. Which action should the nurse take?

• A. Provide information about stress management.
• B. Maintain a warm temperature in the client's room.
• C. Administer epinephrine for acute episodes.
• D. Give glucocorticoid steroids twice a day.

Correct answer: A

Rationale: The correct action for the nurse to take when caring for a client with Raynaud's disease is to provide information about stress management. Raynaud's disease is a condition where the blood vessels narrow in response to cold or stress, leading to reduced blood flow to certain areas of the body, usually the fingers and toes. Stress management helps reduce triggers for Raynaud's disease by minimizing emotional stress, which can trigger vasospasms. Choice B is incorrect as maintaining a warm temperature, rather than a cool one, is recommended for individuals with Raynaud's disease to prevent triggering vasospasms. Choice C is incorrect because epinephrine is not typically used to manage Raynaud's disease, as it can further constrict blood vessels. Choice D is incorrect as glucocorticoid steroids are not a first-line treatment for Raynaud's disease.

3. A nurse is assessing a client who has a history of seizure disorder and is receiving phenytoin. Which of the following findings should the nurse identify as an adverse effect of the medication?

• A. Bradycardia.
• B. Ataxia.
• C. Tachycardia.
• D. Insomnia.

Correct answer: B

Rationale: The correct answer is B: Ataxia. Ataxia, which refers to uncoordinated movements, is a common adverse effect of phenytoin, a medication used to manage seizure disorders. Bradycardia (Choice A) is not typically associated with phenytoin; instead, it may cause tachycardia (Choice C) as a side effect. Insomnia (Choice D) is not a common adverse effect of phenytoin.

4. How should fluid balance be assessed in a patient with heart failure?

• A. Monitor daily weight
• B. Monitor input and output
• C. Check for edema
• D. Monitor blood pressure

Correct answer: A

Rationale: In patients with heart failure, monitoring daily weight is the most accurate method for assessing fluid balance. Weight gain can indicate fluid retention, a common issue in heart failure patients. Monitoring input and output (B) is essential but may not always accurately reflect fluid balance. Checking for edema (C) is important as it can indicate fluid accumulation, but daily weight monitoring is more precise. Monitoring blood pressure (D) is important in heart failure management but does not directly assess fluid balance.

5. What is the best intervention for a patient experiencing respiratory distress?

• A. Administer oxygen
• B. Administer bronchodilators
• C. Administer IV fluids
• D. Reposition the patient

Correct answer: A

Rationale: Administering oxygen is the best intervention for a patient experiencing respiratory distress because it helps improve oxygenation. Oxygen therapy is the initial and priority intervention to ensure an adequate oxygen supply to the body tissues. Administering bronchodilators (Choice B) may be appropriate for specific respiratory conditions like asthma or COPD but is not the first-line intervention in all cases of respiratory distress. Administering IV fluids (Choice C) is not a standard intervention for respiratory distress unless there is an underlying cause like dehydration. Repositioning the patient (Choice D) can aid in optimizing ventilation but is not the primary intervention for respiratory distress.

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