Nursing Elites

1. A nurse is caring for a client who is receiving oxytocin IV for augmentation of labor. The client’s contractions are occurring every 45 seconds with a duration of 90 seconds, and the fetal heart rate is 170-180/minute. Which of the following actions should the nurse take?

• A. Discontinue the oxytocin infusion
• B. Increase the oxytocin infusion
• C. Decrease the oxytocin infusion
• D. Maintain the oxytocin infusion

Correct answer: A

Rationale: In this scenario, the contractions are too frequent (tachysystole), and the fetal heart rate is elevated. Tachysystole can lead to decreased oxygen perfusion to the fetus, causing fetal distress. Therefore, the correct action for the nurse to take is to discontinue the oxytocin infusion to prevent harm to both the mother and fetus. Increasing or maintaining the oxytocin infusion would exacerbate the current situation, potentially leading to further complications. Decreasing the oxytocin infusion may not be sufficient to address the tachysystole and elevated fetal heart rate, making it an inappropriate choice.

2. A client receiving opiates for pain management was initially sedated but is no longer sedated after three days. What action should the nurse take?

• A. Initiate additional non-pharmacological pain management techniques.
• B. Notify the provider that a dosage adjustment is needed.
• C. No action is needed at this time.
• D. Contact the provider to request an alternate method of pain management.

Correct answer: C

Rationale: The correct answer is C: No action is needed at this time. Sedation from opiates commonly decreases as the body adjusts to the medication. It is a positive sign that the sedation has resolved, indicating the client is tolerating the current dosage well. Initiating additional non-pharmacological pain management techniques (Choice A) is unnecessary since the current pain management regimen is effective. Notifying the provider for a dosage adjustment (Choice B) is premature and not indicated when the sedation has resolved. Contacting the provider to request an alternate method of pain management (Choice D) is excessive and not warranted in this situation where the client is no longer sedated and the current pain management plan is effective.

3. A healthcare provider is assessing a client who is receiving heparin therapy for deep vein thrombosis (DVT). Which of the following laboratory values should the provider monitor to evaluate the therapeutic effect of the heparin?

• A. Platelet count
• B. Partial thromboplastin time (PTT)
• C. Prothrombin time (PT)
• D. Bleeding time

Correct answer: B

Rationale: The Partial Thromboplastin Time (PTT) is the correct laboratory value to monitor heparin therapy. PTT measures the time it takes for blood to clot and is specifically used to evaluate the effectiveness of anticoagulation therapy such as heparin. Monitoring the PTT helps ensure that the heparin dose is within the therapeutic range. Platelet count, Prothrombin time (PT), and Bleeding time are not specific laboratory values for monitoring the therapeutic effect of heparin therapy. Platelet count is more indicative of platelet function, PT is used to monitor warfarin therapy, and Bleeding time assesses platelet function rather than the effect of heparin therapy.

4. A client is admitted for observation and has full range of motion. Which is the best manner to encourage the client to void?

• A. Urinal
• B. Bedpan
• C. Bedside Commode
• D. Client Bathroom

Correct answer: D

Rationale: The correct answer is D: Client Bathroom. Encouraging the client to use the bathroom is the best way to promote independence and privacy, maintaining normal function. In this case, since the client has full range of motion, using the client bathroom would be the most appropriate choice. Options A, B, and C (Urinal, Bedpan, Bedside Commode) are not the best choices as they may restrict the client's independence and privacy, which can impact their psychological well-being and normal voiding function.

5. A nurse is preparing to administer a blood transfusion. Which of the following actions should the nurse take first?

• A. Obtain the client's consent
• B. Verify the blood type and crossmatch
• C. Take baseline vital signs
• D. Prime the IV with normal saline

Correct answer: B

Rationale: The correct first action the nurse should take when preparing to administer a blood transfusion is to verify the blood type and crossmatch. This step is crucial to ensure compatibility and prevent transfusion reactions. Obtaining the client's consent is important but should follow the verification process. Taking baseline vital signs is necessary before starting the transfusion, but confirming compatibility takes precedence. Priming the IV with normal saline is a step done before starting the transfusion, after ensuring blood compatibility.

Similar Questions