Nursing Elites

1. A nurse is assisting with performing a nonstress test for a client who is at 39 weeks of gestation. Which of the following instructions should the nurse reinforce with the client?

• A. Do not press the button during baby's movements
• B. You should depress the button when you feel your baby move
• C. Press the button only during contractions
• D. Do not eat before the test

Correct answer: B

Rationale: The correct answer is B because the client should press the button when feeling fetal movement to track the baby's activity. Choice A is incorrect because the client should press the button during movements. Choice C is incorrect as the button should be pressed during fetal movements, not contractions. Choice D is irrelevant to the instructions for the nonstress test.

2. A client has a prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include in the teaching?

• A. Place the tablet under the tongue and wait 10 minutes
• B. Take up to five tablets during an angina episode
• C. Take up to three tablets during a single angina episode
• D. Swallow the tablet with water

Correct answer: C

Rationale: The correct answer is C: 'Take up to three tablets during a single angina episode.' Nitroglycerin can be taken up to three times during an episode to relieve angina. Choice A is incorrect because the client should place the tablet under the tongue and wait for it to dissolve, not wait for 10 minutes. Choice B is incorrect because taking up to five tablets during an angina episode is excessive and not recommended. Choice D is incorrect because nitroglycerin tablets are meant to be taken sublingually, not swallowed.

3. What are the key components of a focused respiratory assessment, and how do you recognize signs of respiratory distress?

• A. Inspection, Palpation, Percussion, Auscultation
• B. Palpation, Inspection, Observation, Auscultation
• C. Percussion, Inspection, Auscultation, Palpation
• D. Inspection, Percussion, Auscultation, Palpation

Correct answer: A

Rationale: The correct answer is A: Inspection, Palpation, Percussion, Auscultation. A focused respiratory assessment should start with inspection (observing the breathing pattern), followed by palpation (feeling for abnormalities like crepitus), percussion (evaluating for dullness or hyperresonance), and auscultation (listening to lung sounds). This systematic approach helps to identify signs of respiratory distress, such as abnormal breath sounds, increased respiratory rate, use of accessory muscles, and cyanosis. Choices B, C, and D are incorrect because they do not follow the standard order and sequence of a focused respiratory assessment.

4. A client has developed phlebitis at the IV site. What is the most appropriate next step?

• A. Apply a warm compress over the IV site
• B. Notify the provider and discontinue the IV infusion
• C. Increase the IV flow rate to clear the blockage
• D. Elevate the extremity and apply an ice pack

Correct answer: B

Rationale: Phlebitis, inflammation of a vein, is a complication that requires prompt action. The most appropriate next step is to discontinue the IV infusion and notify the healthcare provider. Applying a warm compress, increasing the IV flow rate, or applying an ice pack are not appropriate interventions for phlebitis. Warm compresses may worsen inflammation, increasing the IV flow rate could exacerbate the condition, and ice packs are not recommended for phlebitis.

5. What is the first step when administering a blood transfusion?

• A. Warm the blood to body temperature
• B. Verify the client's blood type before administration
• C. Administer the blood through an IV push
• D. Administer diuretics before the transfusion

Correct answer: B

Rationale: The correct answer is to verify the client's blood type before administration. This step is crucial to ensure compatibility and prevent adverse reactions such as hemolytic transfusion reactions. Warming the blood to body temperature (Choice A) is not the first step and is not typically done during blood transfusions. Administering the blood through an IV push (Choice C) is incorrect as blood transfusions are usually administered as a slow infusion. Administering diuretics before the transfusion (Choice D) is unnecessary and not a standard practice when initiating a blood transfusion.

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