Nursing Elites

1. A nurse is caring for a client in active labor who is receiving oxytocin. The nurse notes that the client is experiencing contractions every 1 minute lasting 90 seconds. Which of the following actions should the nurse take?

• A. Stop the oxytocin infusion
• B. Administer oxygen
• C. Increase the IV fluid rate
• D. Prepare for delivery

Correct answer: A

Rationale: The correct action the nurse should take in this situation is to stop the oxytocin infusion. Contractions occurring every 1 minute lasting 90 seconds indicate uterine hyperstimulation, which can lead to fetal distress by compromising oxygen supply. Stopping the oxytocin infusion will help reduce the frequency and intensity of contractions, allowing for better fetal oxygenation. Administering oxygen (Choice B) may be necessary if there are signs of fetal distress, but stopping the oxytocin is the priority. Increasing IV fluid rate (Choice C) is not the appropriate action in response to hyperstimulation. While preparing for delivery (Choice D) may eventually be necessary, the immediate action should be to address the hyperstimulation by stopping the oxytocin infusion.

2. A nurse is teaching a client about the use of alendronate. Which of the following should be included in the teaching?

• A. Take it with food
• B. Sit upright for at least 30 minutes after taking it
• C. It can be taken at bedtime
• D. It is safe to take with antacids

Correct answer: B

Rationale: The correct answer is B: 'Sit upright for at least 30 minutes after taking it.' Alendronate can cause esophageal irritation and to reduce the risk of this side effect, clients should be instructed to sit upright for at least 30 minutes after administration. Choice A is incorrect as alendronate should be taken on an empty stomach, usually in the morning, at least 30 minutes before the first food, beverage, or medication of the day. Choice C is incorrect because alendronate should not be taken at bedtime, as the client should remain upright for at least 30 minutes after taking it. Choice D is incorrect as antacids can interfere with the absorption of alendronate, so they should not be taken together.

3. A nurse is caring for an older adult patient who is disoriented and has a history of falls. What actions should the nurse take?

• A. Place the bed in the lowest position, instruct the patient to remain in bed, ensure the bedside table is within reach.
• B. Instruct the patient to use the call light, apply an ambulation alarm to the patient’s leg, check on the patient hourly.
• C. Assign a sitter to monitor the patient, raise the bed rails, provide the patient with a call button.
• D. Check on the patient every two hours, provide verbal reminders to use the call light, lock the bed wheels.

Correct answer: B

Rationale: In this scenario, the correct actions for the nurse to take involve ensuring patient safety and fall prevention measures. Choice B is the correct answer because instructing the patient to use the call light allows them to signal for help, applying an ambulation alarm helps detect movement, and checking on the patient hourly increases monitoring frequency. These actions are essential for preventing falls in a disoriented patient with a history of falls. Choices A, C, and D are incorrect: A does not provide adequate monitoring or fall prevention measures, C relies solely on assigning a sitter without utilizing technological aids, and D lacks continuous monitoring and specific fall prevention strategies.

4. A nurse is assessing a client who gave birth 1 week ago. The client states, 'I don't know what's wrong. I love my baby, but I feel so let down and I seem to cry for no reason.' The nurse should identify that the client is experiencing which of the following emotional responses to birth?

• A. Postpartum depression
• B. Taking-in phase
• C. Postpartum blues
• D. Taking-hold phase

Correct answer: C

Rationale: The client is experiencing postpartum blues, not postpartum depression. Postpartum blues are common and characterized by mood swings, tearfulness, and emotional letdown shortly after delivery. The 'Taking-in phase' involves the mother focusing on her own needs, while the 'Taking-hold phase' is characterized by a desire to learn and feel competent in caring for the baby. Postpartum depression is a more severe and long-lasting condition that requires professional intervention.

5. A nurse is caring for a client recovering from bowel surgery who has a nasogastric (NG) tube connected to low intermittent suction. Which of the following assessment findings should indicate to the nurse that the NG tube may not be functioning properly?

• A. Drainage fluid is greenish-yellow
• B. Aspirate pH of 3
• C. Abdominal rigidity
• D. Air bubbles noted in the NG tube

Correct answer: C

Rationale: Abdominal rigidity can indicate a serious complication, such as a blockage or infection, requiring immediate intervention to determine if the NG tube is functioning properly. Choices A, B, and D are not indicative of a malfunctioning NG tube. Greenish-yellow drainage fluid may be normal, an aspirate pH of 3 is within the expected range for gastric contents, and air bubbles in the NG tube are not abnormal as long as they are moving.

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