Nursing Elites

1. A client in active labor has ruptured membranes. What action should the nurse take?

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

Correct answer: A

Rationale: When a client in active labor has ruptured membranes, the priority action for the nurse is to apply a fetal heart rate monitor. This is crucial for continuous monitoring of the baby's heart rate and ensuring fetal well-being. Initiating fundal massage may be indicated for uterine atony after delivery, not for ruptured membranes during labor. Administering oxytocin IV could be appropriate in some cases to augment labor, but it is not the immediate priority after ruptured membranes. Inserting an indwelling urinary catheter is not necessary solely based on ruptured membranes; it may be indicated for specific situations like epidural anesthesia where the client cannot void.

2. Which of the following lab values should the nurse monitor for a patient receiving heparin therapy?

• A. Monitor platelet count
• B. Monitor PT/INR
• C. Monitor aPTT
• D. Monitor CBC

Correct answer: C

Rationale: The correct answer is to monitor aPTT for a patient receiving heparin therapy. The activated partial thromboplastin time (aPTT) is used to assess and adjust heparin dosage to ensure the patient is within the therapeutic range for anticoagulation. Monitoring the aPTT helps in preventing both clotting and bleeding complications. Platelet count (Choice A) is important to monitor for patients receiving antiplatelet therapy, not heparin. PT/INR (Choice B) is typically monitored for patients on warfarin therapy, not heparin. Monitoring the complete blood count (CBC) (Choice D) is essential for various conditions but is not specific to monitoring heparin therapy.

3. What is a crucial nursing responsibility when caring for a patient with a central line?

• A. Flush the line with saline
• B. Monitor for infection
• C. Monitor fluid balance
• D. Replace the central line

Correct answer: B

Rationale: When caring for a patient with a central line, monitoring for infection is a crucial nursing responsibility. This is essential to prevent complications such as bloodstream infections. While flushing the line with saline and monitoring fluid balance are important aspects of care, they are not as critical as monitoring for infection. Replacing the central line is only done when necessary due to complications or at the end of its recommended use.

4. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take to prevent infection?

• A. Change the TPN tubing every 48 hours.
• B. Change the TPN tubing every 24 hours.
• C. Monitor the client's urine output every 8 hours.
• D. Monitor the client's weight every 72 hours.

Correct answer: B

Rationale: The correct answer is to change the TPN tubing every 24 hours. This action helps reduce the risk of infection because the high glucose content of TPN promotes bacterial growth. Choice A is incorrect as changing the tubing every 48 hours would not provide adequate infection prevention. Option C, monitoring urine output, is important for assessing renal function but is not directly related to preventing TPN-related infections. Option D, monitoring weight, is essential for assessing nutritional status but does not directly address infection prevention in TPN administration.

5. A healthcare professional is reviewing the laboratory data of a client who has diabetes mellitus. Which of the following laboratory tests is an indicator of long-term disease management?

• A. Postprandial blood glucose
• B. Glycosylated hemoglobin (HbA1c)
• C. Glucose tolerance test
• D. Fasting blood glucose

Correct answer: B

Rationale: Glycosylated hemoglobin (HbA1c) is the most accurate test for long-term management of blood glucose levels in individuals with diabetes mellitus. HbA1c reflects average blood glucose levels over the past 2-3 months, providing valuable information on the effectiveness of treatment and disease control. Postprandial blood glucose, glucose tolerance test, and fasting blood glucose are essential for monitoring blood glucose levels at specific times but do not offer the same insight into long-term disease management as HbA1c.

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