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. A healthcare provider is reviewing the medical records of a client with a prescription for combination oral contraceptives. Which of the following conditions is a contraindication?

• A. Hyperthyroidism
• B. Thrombophlebitis
• C. Diverticulosis
• D. Hypocalcemia

Correct answer: B

Rationale: Thrombophlebitis is a contraindication to combination oral contraceptives due to the increased risk of thromboembolic events. Hyperthyroidism, diverticulosis, and hypocalcemia are not contraindications to combination oral contraceptives. Hyperthyroidism may affect thyroid hormone levels but does not directly contraindicate oral contraceptives. Diverticulosis is a condition related to the digestive system and does not impact the use of oral contraceptives. Hypocalcemia, a low calcium level in the blood, is not a contraindication for oral contraceptives.

3. A nurse is assessing a client who is experiencing auditory hallucinations. What question should the nurse ask?

• A. Do you understand the voices are not real?
• B. Why do you think the voices are talking to you?
• C. Have you tried going to a quiet place when this occurs?
• D. What helps you ignore the voices?

Correct answer: D

Rationale: Exploring strategies to ignore the hallucinations can help clients manage symptoms.

4. A nurse is caring for a client who has pneumonia. Which of the following findings should the nurse identify as an indication of the effectiveness of the treatment?

• A. Respiratory rate of 24/min
• B. White blood cell count of 15,000/mm3
• C. SpO2 of 95%
• D. Clear breath sounds

Correct answer: D

Rationale: Clear breath sounds are an essential indicator of effective pneumonia treatment as they suggest resolution of the lung infection. A normal respiratory rate (A) indicates adequate breathing but does not directly reflect the effectiveness of pneumonia treatment. An elevated white blood cell count (B) is a sign of infection and may not decrease immediately with treatment. While maintaining an SpO2 of 95% (C) is crucial for oxygenation, it may not directly indicate the effectiveness of pneumonia treatment.

5. A healthcare professional is preparing to administer ceftriaxone IM to a client. Which of the following actions should the healthcare professional take?

• A. Administer the medication using a tuberculin syringe
• B. Administer the medication at a 45-degree angle
• C. Use the dorsogluteal muscle for injection
• D. Aspirate for blood return before injecting the medication

Correct answer: D

Rationale: Correct Answer: When administering intramuscular injections like ceftriaxone, it is essential to aspirate for blood return before injecting the medication to ensure that the needle is not in a blood vessel. Choices A and B are incorrect because ceftriaxone is typically administered using a syringe appropriate for IM injections (not a tuberculin syringe) and injected at a 90-degree angle rather than 45 degrees. Choice C is incorrect because the dorsogluteal site is no longer recommended for IM injections due to potential injury to the sciatic nerve and other structures.

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