Nursing Elites

1. While caring for a client in active labor, a nurse notes late decelerations in the FHR on the external fetal monitor. Which of the following actions should the nurse take first?

• A. Change the client's position
• B. Palpate the uterus to assess for tachysystole
• C. Increase the client's IV infusion rate
• D. Administer oxygen at 10 L/min via nonrebreather mask

Correct answer: A

Rationale: The correct initial action for the nurse to take is to change the client's position. This intervention can alleviate pressure on the umbilical cord, potentially improving fetal oxygenation and addressing the underlying cause of late decelerations. Palpating the uterus to assess for tachysystole or increasing the IV infusion rate are not the first-line interventions for addressing late decelerations. Administering oxygen at a high flow rate via a nonrebreather mask may be necessary but is not the priority action in this situation.

2. A healthcare professional is assessing a client for signs of anemia. Which of the following findings should the healthcare professional expect?

• A. Increased energy levels
• B. Pale skin
• C. Elevated blood pressure
• D. Decreased heart rate

Correct answer: B

Rationale: Pale skin is a common sign of anemia due to reduced hemoglobin levels, leading to decreased oxygen delivery to tissues. This results in skin pallor. Choices A, C, and D are incorrect. Anemia typically causes fatigue and decreased energy levels (not increased), low blood pressure (not elevated), and tachycardia (increased heart rate) to compensate for the decreased oxygen-carrying capacity of the blood.

3. A nurse is assessing a client 1 hour after birth and notes a boggy uterus located 2 cm above the umbilicus. What should the nurse do first?

• A. Take vital signs
• B. Assess lochia
• C. Massage the fundus
• D. Give oxytocin IV bolus

Correct answer: C

Rationale: A boggy uterus located 2 cm above the umbilicus suggests uterine atony, which is a common cause of postpartum hemorrhage. The initial intervention in this situation is to massage the fundus. Fundal massage helps the uterus contract, promoting hemostasis and preventing excessive bleeding. Taking vital signs or assessing lochia are important actions but are secondary to addressing uterine atony. Administering oxytocin IV bolus is often done after fundal massage to further enhance uterine contractions.

4. A nurse is caring for a client with a recent diagnosis of myasthenia gravis. Which of the following medications should the nurse expect to administer?

• A. Methotrexate
• B. Pyridostigmine
• C. Baclofen
• D. Atropine

Correct answer: B

Rationale: Pyridostigmine is the drug of choice for treating myasthenia gravis because it enhances communication between nerves and muscles by inhibiting acetylcholinesterase. Methotrexate (choice A) is not indicated for myasthenia gravis but is used in conditions like rheumatoid arthritis. Baclofen (choice C) is a muscle relaxant used for conditions like spasticity. Atropine (choice D) is not typically used in myasthenia gravis as it can worsen muscle weakness.

5. A nurse is preparing to feed a newly admitted client with dysphagia. Which of the following actions should the nurse take?

• A. Instruct the client to lift their chin when swallowing
• B. Discourage the client from coughing during feedings
• C. Sit at or below the client’s eye level during feedings
• D. Talk with the client during feedings

Correct answer: C

Rationale: The correct answer is C. Sitting at or below the client’s eye level is important when feeding a client with dysphagia. This position allows the nurse to closely observe the client for any signs of difficulty with swallowing, which can help prevent aspiration. Instructing the client to lift their chin when swallowing (choice A) is not recommended for clients with dysphagia as it can increase the risk of aspiration. Discouraging the client from coughing during feedings (choice B) is also not correct, as coughing may be a protective mechanism to prevent aspiration. Talking with the client during feedings (choice D) may distract the client and interfere with their ability to focus on swallowing safely.

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