Nursing Elites

1. A nurse is preparing to administer a dose of losartan. Which of the following should the nurse assess first?

• A. Blood pressure
• B. Heart rate
• C. Serum potassium
• D. Liver function

Correct answer: A

Rationale: The correct answer is to assess blood pressure first. Losartan is an angiotensin receptor blocker used to lower blood pressure. Assessing the patient's blood pressure before administering losartan is crucial to ensure it is not already too low, which could lead to hypotension. Assessing heart rate (choice B) is important but not the priority when administering losartan. Serum potassium levels (choice C) and liver function (choice D) are also important assessments, but they are not the primary concern before administering losartan.

2. 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.

3. A nurse observes an assistive personnel (AP) providing care to a child who is in skeletal traction. Which of the following actions requires intervention?

• A. Providing a high-protein snack
• B. Assisting the child to reposition
• C. Placing weights on the child’s bed
• D. Massaging pressure points

Correct answer: C

Rationale: The correct answer is C. Placing weights on the child's bed can alter the traction, which must remain constant to be effective. This action requires immediate intervention to prevent harm. Providing a high-protein snack (Choice A) is appropriate for the child's nutritional needs. Assisting the child to reposition (Choice B) helps prevent complications such as pressure ulcers. Massaging pressure points (Choice D) can help promote circulation and prevent skin breakdown. However, altering the traction by placing weights on the bed can be detrimental to the child's condition and must be corrected promptly.

4. A nurse is developing a plan of care for a newborn who has hyperbilirubinemia and a prescription for phototherapy. Which of the following interventions should the nurse include?

• A. Check the newborn's temperature every 4 hours
• B. Apply moisturizing lotion to the newborn's skin every 4 hours
• C. Give the newborn 1 oz of glucose water every 4 hours
• D. Reposition the newborn every 2 to 3 hours

Correct answer: D

Rationale: Repositioning the newborn every 2 to 3 hours during phototherapy is important to expose all areas of the skin to light and facilitate the breakdown of bilirubin. Checking the newborn's temperature is important, but it should be done more frequently, such as every 4 hours, to monitor for any signs of overheating or hypothermia. Applying moisturizing lotion is not indicated during phototherapy as it may interfere with the treatment. Giving glucose water is not necessary for the management of hyperbilirubinemia.

5. A nurse is assessing a client who is at 31 weeks of gestation. Which of the following findings should the nurse identify as an indication of a potential prenatal complication?

• A. Periodic tingling of fingers
• B. Absence of clonus
• C. Leg cramps
• D. Blurred vision

Correct answer: D

Rationale: Blurred vision can be an indicator of serious conditions such as preeclampsia, which involves hypertension and can lead to significant maternal and fetal complications. Periodic tingling of fingers, absence of clonus, and leg cramps are common discomforts during pregnancy but are not typically associated with serious prenatal complications like preeclampsia. Therefore, the correct answer is D.

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