Nursing Elites

1. A nurse is caring for a client who is in labor and has an external fetal monitor in place. The nurse observes late decelerations in the fetal heart rate. Which of the following actions should the nurse take first?

• A. Decrease the client's IV fluids
• B. Reposition the client
• C. Administer oxygen by face mask
• D. Document the findings

Correct answer: C

Rationale: Administering oxygen by face mask is the priority intervention when late decelerations are observed in the fetal heart rate. Late decelerations indicate uteroplacental insufficiency, and administering oxygen helps to improve fetal oxygenation. Repositioning the client may also be necessary to relieve pressure on the umbilical cord, but providing oxygen takes precedence to enhance fetal oxygenation. Decreasing IV fluids may not directly address the underlying issue leading to late decelerations. Documenting the findings is important but should not be the first action taken when managing late decelerations.

2. A nurse caring for a client under airborne precautions notes that the client is scheduled for a nuclear scan. What is the appropriate action for the nurse to take?

• A. Planning to have the nuclear scan performed at the bedside
• B. Calling the nuclear medicine department and telling the technician that the test will have to be delayed until airborne precautions have been discontinued
• C. Asking the technicians in the nuclear scan department to wear masks
• D. Placing a surgical mask on the client for transport and for contact with other individuals

Correct answer: D

Rationale: The correct action for the nurse is to place a surgical mask on the client for transport and for contact with other individuals when a patient under airborne precautions requires movement. This helps prevent the spread of infectious agents. Planning to have the nuclear scan at the bedside (Choice A) may not be feasible or appropriate. Calling the nuclear medicine department to delay the test (Choice B) may inconvenience the client and disrupt the scheduled procedure. Asking technicians in the nuclear scan department to wear masks (Choice C) does not provide adequate protection for others who may come into contact with the client outside the department.

3. A healthcare professional suspects a colleague of diverting narcotics. What is the first step the healthcare professional should take?

• A. Confront the colleague directly
• B. Report the suspicion to the supervisor
• C. Ignore the issue and continue working
• D. Notify the pharmacy about the colleague's behavior

Correct answer: B

Rationale: The correct first step for a healthcare professional who suspects a colleague of diverting narcotics is to report the suspicion to the supervisor. This action is essential to protect patient safety, uphold ethical standards, and comply with legal obligations. Confronting the colleague directly may not only escalate the situation but also jeopardize the investigation process. Ignoring the issue and continuing to work could potentially harm patients and violate professional responsibilities. Notifying the pharmacy, while important, should come after informing the appropriate supervisor or authority within the healthcare facility.

4. When administering a subcutaneous injection of insulin to a client, what angle should the nurse use for the injection?

• A. 45-degree angle
• B. 60-degree angle
• C. 90-degree angle
• D. 30-degree angle

Correct answer: C

Rationale: The correct angle for administering a subcutaneous injection, such as insulin, is 90 degrees. This angle allows for the medication to be delivered into the subcutaneous layer of tissue beneath the skin. A 45-degree angle is typically used for administering subcutaneous injections in infants or those with reduced adipose tissue, while a 60-degree angle is commonly used for intramuscular injections. A 30-degree angle is not a standard angle for subcutaneous injections.

5. A community health nurse is providing an educational session on childhood poisoning at a local school. What should the nurse advise as the first action if poisoning occurs?

• A. Call the poison control center
• B. Bring the child to the emergency department (ED)
• C. Induce vomiting
• D. Call an ambulance

Correct answer: A

Rationale: In the event of poisoning, the recommended first action is to call the poison control center. Poison control specialists can provide immediate guidance on how to manage the situation effectively. Bringing the child to the emergency department (Choice B) may be necessary depending on the severity of the poisoning, but contacting poison control first is crucial for appropriate and timely intervention. Inducing vomiting (Choice C) is not advised in all cases of poisoning and should only be done under the guidance of healthcare professionals. Calling an ambulance (Choice D) may be necessary in some severe cases, but the initial step should be to contact poison control for expert advice.

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