Nursing Elites

1. A client who is at 38 weeks gestation, is in active labor, and has ruptured membranes is being cared for by a nurse. What action should the nurse take?

• A. Insert an indwelling urinary catheter
• B. Apply fetal heart rate monitor
• C. Initiate fundal massage
• D. Initiate an oxytocin IV infusion

Correct answer: B

Rationale: When caring for a client in active labor with ruptured membranes, the priority action for the nurse is to apply a fetal heart rate monitor. This helps monitor the well-being of the fetus during labor and delivery, enabling timely interventions if any fetal distress is detected. Inserting an indwelling urinary catheter may be required in some cases, but it is not the priority in the given scenario. Fundal massage is typically done after delivery to help the uterus contract and prevent postpartum hemorrhage. Initiating an oxytocin IV infusion may be indicated to augment labor, but it is not the initial action needed in this situation.

2. Which of the following actions should be taken to use a wide base support when assisting a client to get up in a chair?

• A. Bend at the waist and place arms under the client’s arms and lift
• B. Face the client, bend knees, and place hands on the client’s forearm and lift
• C. Spread the feet apart
• D. Tighten the pelvic muscles

Correct answer: C

Rationale: The correct answer is C: Spread the feet apart. When assisting a client to get up in a chair, it is crucial to use a wide base of support to maintain stability and prevent injuries. Spreading the feet apart provides a broader base, increasing balance and support for both the client and the caregiver. This position helps distribute the weight evenly and allows for better control when assisting the client in moving. Choices A, B, and D are incorrect because bending at the waist, placing arms under the client's arms, tightening pelvic muscles, or placing hands on the client's forearm do not provide the necessary wide base support needed for stability and safety during the transfer process.

3. During a Romberg test, the patient is asked to assume which position?

• A. Sitting
• B. Standing
• C. Genupectoral
• D. Trendelenburg

Correct answer: B

Rationale: During a Romberg test, the patient is asked to stand with feet together and arms at the sides. The test evaluates proprioception and vestibular function by assessing the patient's ability to maintain balance with eyes closed. Asking the patient to stand helps to detect any balance issues or disturbances in the absence of visual input.

4. When caring for a client who is to have a line placed for hemodynamic monitoring, which statement by the newly licensed nurse indicates effectiveness of the teaching?

• A. Air should be instilled into the monitoring system after the procedure.
• B. The client should be positioned on the left side after the procedure.
• C. The transducer should be level with the second intercostal space after the line is placed.
• D. A chest x-ray is needed to verify placement after the procedure.

Correct answer: D

Rationale: After a line is placed for hemodynamic monitoring, it is crucial to confirm its correct placement. The definitive way to verify the placement is through a chest x-ray. This ensures that the line is appropriately positioned without complications. Options A, B, and C do not address the essential step of confirming the line's placement, making them incorrect choices.

5. The healthcare professional must verify the client’s identity before the administration of medication. Which of the following is the safest way to identify the client?

• A. Ask the client for their name
• B. Check the client’s identification band
• C. State the client’s name aloud and ask the client to repeat it
• D. Check the room number

Correct answer: B

Rationale: Verifying the client's identity before administering medication is crucial to ensure patient safety. Checking the client’s identification band is the safest and most reliable method to confirm the client's identity. Identification bands are specifically designed to prevent errors in patient identification and help healthcare professionals administer care to the correct individual. Asking the client for their name (Choice A) may lead to errors if the client is unable to communicate or if there is a language barrier. Stating the client’s name aloud and asking them to repeat it (Choice C) relies on the client's ability to respond accurately. Checking the room number (Choice D) does not directly confirm the client's identity and may lead to errors if multiple patients are in the same room.

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