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 caring for a client who is in labor and is receiving electronic fetal monitoring. The nurse notes early decelerations. Which of the following should the nurse expect?

• A. Fetal hypoxia
• B. Head compression
• C. Placenta previa
• D. Umbilical cord prolapse

Correct answer: B

Rationale: In the scenario of early decelerations noted during labor with electronic fetal monitoring, the nurse should expect head compression. Early decelerations are a normal response to fetal head compression during contractions and are not indicative of fetal distress. Choice A, fetal hypoxia, is incorrect as early decelerations are not associated with fetal oxygen deprivation. Choices C and D, placenta previa and umbilical cord prolapse, are unrelated to the scenario described and do not cause early decelerations.

3. A nurse is planning care for a client who is receiving hemodialysis. Which of the following actions should the nurse include in the plan of care?

• A. Withhold all medications until after dialysis.
• B. Rehydrate with dextrose 5% in water for orthostatic hypotension.
• C. Check the vascular access site for bleeding after dialysis.
• D. Give an antibiotic 30 minutes before dialysis.

Correct answer: C

Rationale: The correct action the nurse should include in the plan of care for a client receiving hemodialysis is to check the vascular access site for bleeding after dialysis. This is crucial to detect any bleeding complications and ensure prompt intervention if necessary. Withholding all medications until after dialysis (Choice A) is not appropriate as some medications may need to be administered during dialysis. Rehydrating with dextrose 5% in water for orthostatic hypotension (Choice B) is not directly related to the immediate post-dialysis care. Giving an antibiotic 30 minutes before dialysis (Choice D) is not recommended as timing of medication administration should be based on the specific antibiotic and its pharmacokinetics.

4. A client with a new diagnosis of systemic lupus erythematosus (SLE) is being cared for by a nurse. Which of the following findings should the nurse expect?

• A. Joint pain.
• B. Weight gain.
• C. Butterfly-shaped rash on the face.
• D. Increased appetite.

Correct answer: B

Rationale: The correct answer is B: Weight gain. Weight gain is a common finding in clients with systemic lupus erythematosus due to fluid retention. Joint pain (choice A) is also common in SLE but is not specific to fluid retention. A butterfly-shaped rash on the face (choice C) is a classic symptom of SLE but is not related to fluid retention. Increased appetite (choice D) is less likely in SLE compared to weight gain.

5. What is the most important nursing action for a patient presenting with confusion after surgery?

• A. Administer oxygen
• B. Reposition the patient
• C. Administer IV fluids
• D. Perform a neurological assessment

Correct answer: A

Rationale: Administering oxygen is crucial for a patient presenting with confusion after surgery because it helps alleviate potential hypoxia, which can be a common cause of confusion in the postoperative period. While repositioning the patient, administering IV fluids, and performing a neurological assessment are important nursing interventions in certain situations, addressing hypoxia by administering oxygen takes priority in this case to ensure an adequate oxygen supply to the brain and other vital organs.

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