Nursing Elites

1. A nurse is caring for a client who is in labor and receiving electronic fetal monitoring. The nurse is reviewing the monitor tracing and notes early decelerations. What should the nurse expect?

• A. Fetal hypoxia
• B. Abruptio placentae
• C. Post maturity
• D. Head compression

Correct answer: D

Rationale: Corrected Rationale: Early decelerations are caused by head compression resulting from the fetal head being compressed during contractions. They are considered benign and do not indicate fetal distress. Choice A, fetal hypoxia, is incorrect because early decelerations are not associated with fetal hypoxia. Choice B, abruptio placentae, is incorrect as it is a condition where the placenta prematurely separates from the uterine wall. Choice C, post maturity, is incorrect as it refers to a fetus that remains in the uterus past the due date.

2. A nurse is planning to administer a blood transfusion to a client. Which of the following should the nurse do to prevent an adverse transfusion reaction?

• A. Verify the client's blood type with the provider's prescription
• B. Ensure the client's consent for the transfusion is on file
• C. Administer a diuretic prior to starting the transfusion
• D. Check the client's temperature prior to the transfusion

Correct answer: A

Rationale: The correct answer is to verify the client's blood type with the provider's prescription. This is crucial to prevent an adverse transfusion reaction due to incompatibility. Ensuring the blood type matches before starting the transfusion is a standard safety practice. Option B, ensuring client consent, is important but not directly related to preventing a transfusion reaction. Option C, administering a diuretic, is unnecessary and can be harmful in this context. Option D, checking the client's temperature, is important for general assessment but not specifically focused on preventing a transfusion reaction.

3. A client is postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 90/min
• B. Temperature of 37.1°C (98.8°F)
• C. Serosanguineous wound drainage
• D. Urine output of 25 mL/hr

Correct answer: D

Rationale: A urine output of 25 mL/hr is a sign of oliguria, which may indicate dehydration or kidney impairment and should be reported. A heart rate of 90/min is within the normal range (60-100/min) for adults at rest and may be expected postoperatively. A temperature of 37.1°C (98.8°F) is within the normal range (36.1-37.2°C or 97-99°F) and does not indicate an immediate concern. Serosanguineous wound drainage is a common finding postoperatively and indicates a normal healing process.

4. A nurse is providing teaching to a client with asthma. Which of the following client statements indicates a need for further teaching?

• A. I should use my albuterol inhaler before I exercise.
• B. I should avoid using my inhaler more than twice a week.
• C. I should take my inhaler only when I feel short of breath.
• D. I should rinse my mouth after using my corticosteroid inhaler.

Correct answer: C

Rationale: The correct answer is C because the client stating they should only take the inhaler when feeling short of breath indicates a need for further teaching. Clients with asthma should use their inhaler as prescribed, not just when short of breath. Choices A, B, and D demonstrate good asthma management practices. Choice A indicates understanding of using the albuterol inhaler before exercise to prevent exercise-induced symptoms. Choice B mentions the importance of not overusing the inhaler, which can indicate poor asthma control. Choice D shows awareness of rinsing the mouth after using a corticosteroid inhaler to prevent oral thrush.

5. A client is being discharged with a new prescription for levothyroxine. Which of the following instructions should the nurse include?

• A. Take this medication with meals to avoid stomach upset.
• B. Take this medication at the same time every day.
• C. Notify your provider if you experience chest pain or palpitations.
• D. Take this medication with antacids to reduce indigestion.

Correct answer: B

Rationale: The correct answer is B: 'Take this medication at the same time every day.' It is crucial to take levothyroxine at the same time each day to maintain consistent thyroid hormone levels. Choice A is incorrect because levothyroxine should be taken on an empty stomach, usually in the morning. Choice C is important but not specific to the administration of levothyroxine. Choice D is incorrect as antacids can interfere with the absorption of levothyroxine.

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