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 stroke. Which of the following should the healthcare professional look for?

• A. Slurred speech
• B. Increased appetite
• C. Elevated heart rate
• D. Hyperactivity

Correct answer: A

Rationale: Corrected Question: A healthcare professional is assessing a client for signs of stroke. Slurred speech is a common sign of stroke and should be assessed immediately. Choices B, C, and D are incorrect because increased appetite, elevated heart rate, and hyperactivity are not typical signs of a stroke.

3. A client with multiple sclerosis reports diplopia. Which of the following actions should the nurse take?

• A. Encourage the client to focus on a distant object.
• B. Apply a warm compress to the client’s eyes.
• C. Recommend alternating eye patches during the day.
• D. Administer artificial tears.

Correct answer: C

Rationale: The correct action for the nurse to take when caring for a client with multiple sclerosis reporting diplopia is to recommend alternating eye patches during the day. This strategy can help relieve diplopia (double vision) by allowing each eye to rest alternately, reducing eye strain. Encouraging the client to focus on a distant object (Choice A) is not an appropriate intervention for diplopia in this case. Applying a warm compress to the client's eyes (Choice B) and administering artificial tears (Choice D) are not effective interventions for diplopia associated with multiple sclerosis.

4. A nurse is preparing to perform a sterile dressing change for a client with a surgical wound. Which action should the nurse take to prevent contamination during the dressing change?

• A. Proceed with the dressing change
• B. Restart the procedure if the sterile solution splashes onto the sterile field
• C. Continue without concern for minor splashes
• D. Delegate the task to another nurse

Correct answer: B

Rationale: The correct action for the nurse to take to prevent contamination during a sterile dressing change is to restart the procedure if the sterile solution splashes onto the sterile field. Any contamination of the sterile field compromises the aseptic technique and increases the risk of infection for the client. Therefore, it is crucial to maintain the sterility of the field throughout the procedure. Choices A, C, and D are incorrect because proceeding with the dressing change, continuing without concern for minor splashes, or delegating the task to another nurse would all compromise the sterility of the procedure and increase the risk of infection for the client.

5. A nurse is assessing a client diagnosed with schizophrenia. The nurse asks the client to interpret the following statement: “When the cat’s away, the mice will play.” The client responds, “The mice come out when the cat is not around.” The nurse should document this finding as:

• A. Echolalia
• B. Associative looseness
• C. Neologisms
• D. Concrete thinking

Correct answer: D

Rationale: The client’s literal interpretation of the statement is an example of concrete thinking, a cognitive symptom often seen in schizophrenia where abstract thinking is impaired. Choice A, Echolalia, is the repetition of words spoken by others, which is not demonstrated in this scenario. Choice B, Associative looseness, refers to a disturbance in the logical progression of thoughts, leading to a disorganized thought process. Choice C, Neologisms, involves creating new words or phrases with unique meanings, which is not evident in the client's response.

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