Nursing Elites

1. A nurse is caring for a client who is at 41 weeks of gestation and is receiving oxytocin for labor induction. The nurse notes early decelerations on the fetal heart rate monitor. Which of the following nursing actions should the nurse take?

• A. Continue to monitor the fetal heart rate.
• B. Stop the oxytocin infusion.
• C. Perform a vaginal examination.
• D. Initiate an amnioinfusion.

Correct answer: A

Rationale: The correct action for early decelerations, which are caused by fetal head compression and are considered normal during labor, is to continue monitoring the fetal heart rate. Early decelerations mirror contractions and usually do not require any intervention. Stopping the oxytocin infusion (Choice B) is not necessary as early decelerations are not typically a cause for concern related to oxytocin. Performing a vaginal examination (Choice C) or initiating an amnioinfusion (Choice D) are unnecessary and not indicated specifically for early decelerations.

2. A client is postoperative following a hip replacement. Which of the following interventions should the nurse implement to prevent dislocation of the prosthesis?

• A. Encourage the client to bend at the waist
• B. Maintain the client in a high-Fowler's position
• C. Place a pillow between the client's legs
• D. Avoid placing a pillow under the client's knees

Correct answer: C

Rationale: Placing a pillow between the client's legs is beneficial after hip replacement surgery to maintain proper alignment and prevent dislocation of the prosthesis. This position helps keep the hip in a neutral position, reducing the risk of dislocation. Encouraging the client to bend at the waist (Choice A) can increase the risk of hip dislocation. Maintaining the client in a high-Fowler's position (Choice B) and avoiding placing a pillow under the client's knees (Choice D) do not directly address the need to maintain proper alignment of the hip joint to prevent dislocation.

3. A healthcare provider is reviewing the medical record of a client who is scheduled for an abdominal paracentesis. Which of the following actions should the healthcare provider take to prepare the client for this procedure?

• A. Assist the client to void
• B. Instruct the client to hold their breath
• C. Place the client in a lateral recumbent position
• D. Prepare to administer a sedative

Correct answer: A

Rationale: Assisting the client to void before a paracentesis is essential to reduce the risk of bladder injury during the procedure. Voiding helps empty the bladder, preventing accidental puncture during the insertion of the needle. Instructing the client to hold their breath is incorrect and can increase the risk of complications. Placing the client in a lateral recumbent position is not directly related to bladder safety during a paracentesis. Preparing to administer a sedative is not a standard preparation for this procedure and is not aimed at preventing bladder injury.

4. A nurse is caring for a client who is 2 hours postoperative following a colon resection. Which of the following assessments is the nurse's priority?

• A. Capillary refill
• B. Bowel sounds
• C. Temperature
• D. Oxygen saturation

Correct answer: D

Rationale: The correct answer is D: Oxygen saturation. The priority assessment in this situation is oxygen saturation because postoperative clients are at risk for respiratory complications, such as hypoxia due to factors like anesthesia effects, impaired lung function, or pain interfering with deep breathing. Monitoring oxygen saturation is crucial to detect any respiratory compromise early. Capillary refill, bowel sounds, and temperature are important assessments but are not the priority in this immediate postoperative period.

5. A client has a new diagnosis of Raynaud's disease. Which of the following instructions should the nurse include?

• A. Increase your intake of foods high in potassium.
• B. Keep your home environment warm.
• C. Elevate your legs when sitting.
• D. Reduce your intake of sodium.

Correct answer: B

Rationale: The correct answer is to keep the home environment warm. Raynaud's disease causes vasospasm in response to cold, so maintaining a warm environment can help prevent attacks. Choices A, C, and D are incorrect. Increasing potassium intake, elevating legs when sitting, or reducing sodium intake are not specific to managing Raynaud's disease.

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