Nursing Elites

1. A client receiving oxytocin IV for labor augmentation is experiencing contractions every 45 seconds. What action 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: The correct action for the nurse to take in this situation is to discontinue the oxytocin infusion. Contractions occurring every 45 seconds indicate uterine hyperstimulation, which can pose risks to both the client and the fetus. By stopping the oxytocin infusion, the nurse can help prevent further complications. Choices B, C, and D are incorrect because increasing, decreasing, or maintaining the oxytocin infusion can exacerbate the uterine hyperstimulation and increase the risks associated with it.

2. A nurse is planning care to prevent complications in a client with immobility. Which of the following interventions should the nurse include?

• A. Massage lower extremities daily to prevent DVT
• B. Remove anti-embolism stockings for 3 hours each day
• C. Limit intake of foods high in calcium to prevent renal calculi
• D. Encourage the client to lie supine to prevent constipation

Correct answer: B

Rationale: The correct answer is B because removing anti-embolism stockings for short periods prevents skin breakdown while ensuring that the stockings remain effective in promoting circulation. Choice A is incorrect because massaging lower extremities daily does not prevent DVT; instead, it may dislodge a clot. Choice C is incorrect as limiting intake of foods high in calcium does not prevent renal calculi; rather, it may help reduce the risk of kidney stones. Choice D is incorrect because encouraging the client to lie supine does not prevent constipation; instead, encouraging mobility and adequate fluid intake can help prevent constipation in immobile clients.

3. A nurse is caring for a client with a history of heroin use who is intoxicated. Which finding should the nurse expect?

• A. Constricted pupils
• B. Dilated pupils
• C. Increased reflexes
• D. Elevated blood pressure

Correct answer: A

Rationale: The correct answer is A: Constricted pupils. Constricted pupils are a classic sign of opioid intoxication, including heroin. Opioids like heroin cause the pupils to constrict due to their effect on the autonomic nervous system. Dilated pupils, increased reflexes, and elevated blood pressure are not typically associated with opioid intoxication but may be seen with other substances or conditions.

4. Which of the following are contraindications to salicylic acid therapy?

• A. Third trimester of pregnancy
• B. Thrombocytopenia
• C. Coronary artery disease
• D. Adolescents with chickenpox

Correct answer: A

Rationale: The correct answer is A: Third trimester of pregnancy. Salicylic acid is contraindicated during the third trimester of pregnancy due to the risk of complications for both the mother and the fetus. Thrombocytopenia (choice B) is not a contraindication to salicylic acid therapy. Coronary artery disease (choice C) is not a specific contraindication to salicylic acid therapy. However, caution should be exercised in patients with coronary artery disease due to the antiplatelet effects of salicylic acid. Adolescents with chickenpox (choice D) should not be given salicylic acid due to the risk of Reye Syndrome, a rare but serious illness.

5. A nurse is teaching a client about the use of fluoxetine. Which of the following should be included?

• A. It can take several weeks for effects to be noticed
• B. It is an antipsychotic medication
• C. It should be taken at night
• D. It has no side effects

Correct answer: A

Rationale: Corrected Rationale: When educating a client about fluoxetine, it is essential to mention that it can take several weeks for the therapeutic effects to be noticed. This is because fluoxetine is an SSRI that requires time to build up in the body and start producing its intended effects. Choice B is incorrect as fluoxetine is not an antipsychotic medication but an SSRI. Choice C is inaccurate because fluoxetine can be taken at any time of the day, and there is no specific requirement to take it at night. Choice D is incorrect as all medications, including fluoxetine, have potential side effects that should be discussed with the client.

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