Nursing Elites

1. A client is preparing advance directives. Which of the following statements by the client indicates an understanding of advance directives?

• A. I cannot change my instructions once they are made
• B. My doctor will need to approve my advance directives
• C. I need an attorney to witness my signature on the advance directives
• D. I have the right to refuse treatment

Correct answer: D

Rationale: The correct answer is D: 'I have the right to refuse treatment.' This statement indicates an understanding of advance directives because advance directives allow individuals to express their treatment preferences, including the right to refuse treatment if they choose to do so. Choice A is incorrect because individuals can update or change their advance directives as needed. Choice B is incorrect because advance directives are based on the individual's preferences, not the doctor's approval. Choice C is incorrect as witnessing an advance directive typically requires a witness who is not an attorney, depending on the state's specific requirements.

2. A nurse is caring for a client who has a new diagnosis of tuberculosis (TB). The client has a productive cough and is started on airborne precautions. Which of the following interventions should the nurse implement?

• A. Wear an N95 respirator mask when caring for the client.
• B. Place the client in a semi-private room.
• C. Have the client wear a surgical mask during meals.
• D. Use a negative pressure air filtration system.

Correct answer: A

Rationale: The correct answer is to wear an N95 respirator mask when caring for the client with TB. This is crucial to prevent the nurse from inhaling the airborne particles that spread the infection. Choice B is incorrect because placing the client in a semi-private room does not address the protection of the nurse. Choice C is incorrect as having the client wear a surgical mask during meals is not sufficient to protect the nurse during all interactions. Choice D is incorrect as using a negative pressure air filtration system is more applicable to airborne infection isolation rooms in healthcare settings and not a standard intervention for nurses caring for a single client with TB.

3. A nurse is caring for a client who is in active labor. The nurse notes early decelerations in the FHR on the fetal monitor tracing. The nurse should identify that which of the following conditions causes early decelerations in the FHR?

• A. Fetal hypoxemia
• B. Cord compression
• C. Uteroplacental insufficiency
• D. Head compression

Correct answer: D

Rationale: Early decelerations are caused by head compression during contractions, which is a normal response as the fetal head is being compressed during uterine contractions. This usually indicates that the fetus is descending into the birth canal. Choices A, B, and C are incorrect. Fetal hypoxemia, cord compression, and uteroplacental insufficiency typically present with variable or late decelerations on the fetal heart rate tracing, not early decelerations.

4. A nurse is caring for a client receiving radiation treatments for cancer. The client states he is experiencing dryness, redness, and scaling at the treatment area. Which of the following should the nurse instruct the client to do?

• A. Sit in the sun for 15 minutes per day.
• B. Apply moist heat to the area twice daily.
• C. Liberally apply prescribed lotion to the area.
• D. Wash the affected area daily with antimicrobial soap.

Correct answer: C

Rationale: The nurse should instruct the client to liberally apply prescribed lotion to the treatment area. Prescribed hydrating lotions help soothe and protect irradiated skin, reducing dryness, redness, and scaling. Sitting in the sun can further damage the skin. Applying moist heat may exacerbate the skin condition. Washing the area with antimicrobial soap can be too harsh and further irritate the skin.

5. A nurse is caring for a client in active labor who is receiving oxytocin. The nurse notes that the client is experiencing contractions every 1 minute lasting 90 seconds. Which of the following actions should the nurse take?

• A. Stop the oxytocin infusion
• B. Administer oxygen
• C. Increase the IV fluid rate
• D. Prepare for delivery

Correct answer: A

Rationale: The correct action the nurse should take in this situation is to stop the oxytocin infusion. Contractions occurring every 1 minute lasting 90 seconds indicate uterine hyperstimulation, which can lead to fetal distress by compromising oxygen supply. Stopping the oxytocin infusion will help reduce the frequency and intensity of contractions, allowing for better fetal oxygenation. Administering oxygen (Choice B) may be necessary if there are signs of fetal distress, but stopping the oxytocin is the priority. Increasing IV fluid rate (Choice C) is not the appropriate action in response to hyperstimulation. While preparing for delivery (Choice D) may eventually be necessary, the immediate action should be to address the hyperstimulation by stopping the oxytocin infusion.

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