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 caring for a client who has been prescribed methadone. Which of the following client statements indicates a need for further teaching?

• A. I understand methadone slows my breathing.
• B. I understand methadone may cause me to have trouble sleeping.
• C. I will avoid alcohol while I’m taking this medication.
• D. I’ll change positions slowly, especially when standing.

Correct answer: B

Rationale: The correct answer is B because methadone typically causes sedation and respiratory depression, not trouble sleeping. The statement about trouble sleeping indicates a need for further teaching. Choices A, C, and D are incorrect because understanding that methadone slows breathing, avoiding alcohol while taking the medication, and changing positions slowly to prevent dizziness are all appropriate client statements when prescribed methadone.

3. A nurse is preparing to administer medications to a client who is NPO and has an NG tube for suction. Which of the following actions should the nurse take?

• A. Mix medications with enteral feedings.
• B. Clamp the NG tube for 30 minutes after medication administration.
• C. Insert medications directly into the NG tube without dilution.
• D. Connect the NG tube to continuous suction after medication.

Correct answer: B

Rationale: The correct action for the nurse to take when administering medications to a client with an NG tube for suction who is NPO is to clamp the NG tube for 30 minutes after medication administration. This is done to allow for proper absorption of the medications before resuming suction. Choice A is incorrect because medications should not be mixed with enteral feedings as it may affect the drug's effectiveness. Choice C is incorrect as medications should not be inserted directly into the NG tube without dilution, as this can cause clogging or affect the tube. Choice D is incorrect because connecting the NG tube to continuous suction after medication administration can interfere with the absorption of the medications.

4. A client is prescribed warfarin for anticoagulation. Which of the following laboratory values should the nurse monitor?

• A. PT and INR
• B. Blood glucose levels
• C. Complete blood count (CBC)
• D. Platelet count

Correct answer: A

Rationale: The correct answer is A: PT and INR. Warfarin is an anticoagulant that affects the clotting mechanism by inhibiting vitamin K-dependent clotting factors. The PT (Prothrombin Time) and INR (International Normalized Ratio) are specific laboratory values used to monitor the effectiveness and safety of warfarin therapy. These values help healthcare providers adjust the warfarin dosage to maintain the desired level of anticoagulation. Choices B, C, and D are incorrect because blood glucose levels, complete blood count (CBC), and platelet count are not directly monitored to assess the effects of warfarin therapy.

5. A client diagnosed with pneumonia is receiving oxygen therapy at 4 L/min via nasal cannula. Which of the following interventions is most important?

• A. Encourage fluid intake.
• B. Monitor oxygen saturation levels.
• C. Change the oxygen tubing daily.
• D. Assist with frequent position changes.

Correct answer: B

Rationale: Monitoring oxygen saturation levels is the most important intervention in this scenario. It ensures that the client is receiving adequate oxygenation, which is crucial for a client with pneumonia. By monitoring saturation levels, the nurse can promptly identify any oxygenation issues and adjust the oxygen delivery if necessary. Encouraging fluid intake, changing oxygen tubing daily, and assisting with frequent position changes are also important aspects of care for a client with pneumonia, but they are not as critical as monitoring oxygen saturation levels in ensuring immediate respiratory support.

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