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 assessing a client who is 2 hours postoperative following a gastrectomy. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 94/min
• B. Oxygen saturation of 88%
• C. Respiratory rate of 18/min
• D. Temperature of 37.6°C (99.7°F)

Correct answer: B

Rationale: An oxygen saturation of 88% indicates hypoxemia, which is a serious condition post-gastrectomy. Hypoxemia can lead to inadequate oxygen delivery to tissues, potentially causing complications like organ dysfunction or failure. This finding requires immediate attention to prevent further deterioration. The heart rate, respiratory rate, and temperature are within normal ranges for a client post-gastrectomy, so they do not require immediate reporting to the provider.

3. A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take?

• A. Place the client in a negative pressure room.
• B. Wear a surgical mask when entering the client's room.
• C. Place the client in droplet isolation.
• D. Place a surgical mask on the client when transporting them.

Correct answer: A

Rationale: The correct answer is to place the client in a negative pressure room. This action is necessary to prevent the spread of tuberculosis, as it is transmitted via airborne particles. Placing the client in droplet isolation (choice C) is not sufficient for tuberculosis, as it requires airborne precautions. Wearing a surgical mask (choice B) when entering the client's room may not provide adequate protection against airborne transmission. Placing a surgical mask on the client when transporting them (choice D) does not address the need for environmental controls to contain infectious particles.

4. A client has a nasogastric tube for gastric decompression. Which of the following actions should the nurse take?

• A. Check for the presence of bowel sounds every 8 hours.
• B. Flush the NG tube every 24 hours.
• C. Provide the client with sips of water every 2 hours.
• D. Keep the client's head of the bed elevated to 45 degrees.

Correct answer: D

Rationale: The correct answer is to keep the client's head of the bed elevated to 45 degrees. This position helps prevent aspiration in clients with a nasogastric tube for gastric decompression by reducing the risk of reflux and promoting proper drainage. Choice A is incorrect because checking for bowel sounds is not directly related to the care of a nasogastric tube. Choice B is incorrect as flushing the NG tube every 24 hours is not a standard nursing practice and may lead to complications. Choice C is incorrect because providing sips of water may interfere with the purpose of gastric decompression, which is to keep the stomach empty.

5. A nurse in the PACU is caring for a client who reports nausea. Which of the following actions should the nurse take first?

• A. Turn the client on their side.
• B. Administer an analgesic.
• C. Administer antiemetic.
• D. Monitor the client's vital signs.

Correct answer: A

Rationale: The correct action the nurse should take first when a client reports nausea in the PACU is to turn the client on their side. This action helps prevent aspiration in a client with nausea, reducing the risk of choking or inhaling vomitus. Administering an analgesic (Choice B) is not the priority in this situation unless pain is the primary cause of nausea. While administering an antiemetic (Choice C) can help relieve nausea, it is not the initial action to prevent aspiration. Monitoring the client's vital signs (Choice D) is important but should come after ensuring the client's safety by turning them on their side.

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