Nursing Elites

1. A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?

• A. Contractions lasting 80 seconds.
• B. FHR baseline 170/min.
• C. Early decelerations in the FHR.
• D. Temperature 37.4°C (99.3°F).

Correct answer: B

Rationale: The correct answer is B. An FHR baseline of 170/min is considered tachycardia, which is above the normal range during labor and requires immediate attention. High FHR can indicate fetal distress or maternal fever. Choice A, contractions lasting 80 seconds, are within normal range for active labor. Choice C, early decelerations in the FHR, are usually benign and do not typically require immediate intervention. Choice D, a temperature of 37.4°C (99.3°F), is within normal limits.

2. A nurse is providing teaching to a client who has a new prescription for clopidogrel. Which of the following instructions should the nurse include?

• A. Avoid eating foods high in potassium.
• B. Avoid drinking alcohol while taking this medication.
• C. Take this medication with a full glass of water.
• D. Take this medication with a full glass of water.

Correct answer: C

Rationale: The correct answer is C. Clients taking clopidogrel should take the medication with a full glass of water to prevent gastrointestinal irritation. Choice A is incorrect because there is no specific recommendation to avoid foods high in potassium with clopidogrel. Choice B is unrelated to the medication's administration. Choice D is a duplication of choice C, providing no additional information.

3. Which electrolyte imbalance is most concerning for a patient on loop diuretics?

• A. Hypokalemia
• B. Hyponatremia
• C. Hyperkalemia
• D. Hypercalcemia

Correct answer: A

Rationale: The correct answer is hypokalemia. Loop diuretics can cause potassium depletion leading to hypokalemia, which is particularly concerning as it can result in cardiac arrhythmias. Hyponatremia (choice B) is not typically associated with loop diuretics. Hyperkalemia (choice C) is less common in patients on loop diuretics. Hypercalcemia (choice D) is not a typical electrolyte imbalance associated with loop diuretics.

4. A client who has a new diagnosis of type 2 diabetes mellitus is being taught about foot care by a nurse. Which of the following statements should the nurse include?

• A. Use lotion on your feet to prevent dry, cracked skin, avoiding application between the toes.
• B. Avoid soaking your feet in warm water daily to prevent dry skin.
• C. Trim your toenails straight across to prevent injury.
• D. Do not apply a heating pad to your feet if they feel cold.

Correct answer: C

Rationale: The correct answer is C. Trimming toenails straight across is essential for clients with diabetes to prevent the risk of ingrown toenails and injury. Using lotion on feet can be beneficial but should not be applied between the toes to avoid moisture buildup, which can lead to infections. Soaking feet in warm water can lead to dry skin, increasing the risk of cracks and other complications. Applying a heating pad to feet when they feel cold is not recommended for clients with diabetes due to impaired sensation, which can result in burns and other injuries.

5. A healthcare provider is reviewing laboratory results for a client who is receiving heparin therapy. Which of the following results indicates that the medication is effective?

• A. Platelets 250,000/mm³
• B. aPTT 60 seconds
• C. Hemoglobin 15 g/dL
• D. INR 1.5

Correct answer: B

Rationale: An aPTT of 60 seconds indicates that the client is receiving an effective dose of heparin. The activated partial thromboplastin time (aPTT) measures the time it takes for blood to clot and is used to monitor heparin therapy. A therapeutic range for aPTT during heparin therapy is usually 1.5 to 2 times the control value, which is around 25-35 seconds. Platelets, hemoglobin, and INR values are not direct indicators of the effectiveness of heparin therapy.

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