Nursing Elites

1. A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations of the FHR. Which of the following actions should the nurse take first?

• A. Prepare the equipment necessary to initiate an amnioinfusion
• B. Administer oxygen at 10 L/min via a non-rebreather face mask
• C. Discontinue the infusion of oxytocin
• D. Place the client in a left lateral position

Correct answer: C

Rationale: The correct first action for the nurse to take is to discontinue the infusion of oxytocin. Oxytocin can lead to uterine hyperstimulation and fetal distress, contributing to variable decelerations in fetal heart rate. By stopping the oxytocin infusion, the nurse can promptly assess and manage the fetal heart rate. Choice A, preparing for amnioinfusion, is not the priority when faced with recurrent variable decelerations. Choice B, administering oxygen, is important but addressing the oxytocin infusion issue takes precedence. Choice D, placing the client in a left lateral position, is beneficial for optimizing fetal oxygenation but discontinuing oxytocin is the initial step in managing variable decelerations.

2. A school nurse is providing care for students in an elementary education facility. What intervention by the nurse addresses the primary level of prevention?

• A. Monitor for signs of illness.
• B. Teach students about healthy food choices.
• C. Administer medication to students with chronic conditions.
• D. Monitor immunization compliance.

Correct answer: B

Rationale: The correct answer is B: Teach students about healthy food choices. Teaching healthy habits like proper nutrition is an example of primary prevention because it aims to prevent disease before it occurs. Choice A, monitoring for signs of illness, is more related to secondary prevention (early detection and treatment). Choice C, administering medication to students with chronic conditions, is a form of tertiary prevention (managing existing conditions to prevent complications). Choice D, monitoring immunization compliance, is also a form of primary prevention but focuses on preventing specific infectious diseases through immunization rather than general health promotion.

3. A client with a new ileostomy is receiving discharge instructions from a nurse. Which statement indicates the client understands the teaching?

• A. I will make sure my medications are enteric-coated.
• B. My stoma will drain liquid continuously.
• C. I will change my pouch system every two weeks.
• D. My stoma size will stay the same after it heals.

Correct answer: B

Rationale: The correct answer is B. Ileostomy stomas typically drain liquid continuously, unlike colostomies. This continuous drainage is a key characteristic that clients should understand postoperatively. Choice A is incorrect because ensuring medications are enteric-coated is not directly related to understanding ileostomy care. Choice C is incorrect as changing the pouch system every two weeks is not a general rule and may vary depending on the individual's needs. Choice D is incorrect because the stoma size can change during the healing process and clients should be informed about this possibility.

4. A client who has undergone a cesarean birth is receiving discharge instructions from a nurse. Which of the following should the nurse include in the instructions?

• A. Limit stair climbing for the first few weeks
• B. Avoid lifting anything heavier than the newborn
• C. Use a pillow to support the abdomen when coughing or sneezing
• D. All of the above

Correct answer: D

Rationale: After a cesarean birth, it is important for the client to follow specific instructions for optimal recovery. Limiting stair climbing reduces strain on the incision site, aiding in healing (Choice A). Avoiding lifting anything heavier than the newborn prevents stress on the incision, promoting recovery (Choice B). Using a pillow to support the abdomen during coughing or sneezing helps reduce discomfort and protect the incision, preventing sudden movements or strain (Choice C). Therefore, all the options provided are crucial post-cesarean birth instructions to ensure proper healing and recovery. Choices A, B, and C are all essential components of post-cesarean care, making Option D the correct answer.

5. A client with type 1 DM is being taught about hypoglycemia by a nurse. Which statement by the client indicates an understanding of the teaching?

• A. “Exercise decreases the risk of hypoglycemia.”
• B. “I should skip my insulin if I don't eat.”
• C. “I can drink 4 oz of regular soda if my blood sugar is low.”
• D. “Oral diabetic medications do not lead to hypoglycemia; only insulin does.”

Correct answer: C

Rationale: The correct answer is C because the client should have a quick-acting source of 15 g of carbohydrates to treat hypoglycemic episodes, such as 4 oz of regular soda. Choice A is incorrect because while exercise can help manage blood sugar levels, it can also increase the risk of hypoglycemia if not properly managed. Choice B is incorrect as skipping insulin when not eating can lead to hyperglycemia, not prevent hypoglycemia. Choice D is incorrect because certain oral diabetic medications can indeed cause hypoglycemia, not just insulin.

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