Nursing Elites

1. While reviewing the monitor tracing of a client in labor, a nurse notes late decelerations. Which of the following interventions should the nurse perform?

• A. Administer oxygen via nasal cannula
• B. Reposition the client onto her left side
• C. Administer an amnioinfusion
• D. Provide reassurance to the client

Correct answer: B

Rationale: Repositioning the client onto her left side is the appropriate intervention when late decelerations are noted on the monitor tracing. This action helps increase uteroplacental blood flow by relieving pressure on the vena cava and aorta, improving fetal oxygenation. Administering oxygen via nasal cannula may be indicated for variable decelerations, not late decelerations. Administering an amnioinfusion is not the primary intervention for late decelerations. Providing reassurance to the client is important but addressing the underlying cause of late decelerations takes precedence.

2. What is the best way to manage a patient with suspected deep vein thrombosis (DVT)?

• A. Administer anticoagulants
• B. Apply compression stockings
• C. Encourage ambulation
• D. Monitor oxygen saturation

Correct answer: A

Rationale: The correct answer is A: Administer anticoagulants. Administering anticoagulants is crucial in managing patients with suspected DVT as it helps prevent further clot formation and reduces the risk of complications like pulmonary embolism. Choice B, applying compression stockings, is more focused on preventing DVT in high-risk patients rather than managing an established case. Encouraging ambulation, choice C, is beneficial in the prevention of DVT but is not the primary management for suspected cases. Monitoring oxygen saturation, choice D, is important in overall patient care but is not the primary intervention for suspected DVT.

3. A nurse is providing teaching to a client who has been prescribed digoxin for heart failure. Which of the following instructions should the nurse include?

• A. Take this medication with meals.
• B. Check your pulse before taking this medication.
• C. Take this medication with an antacid to reduce stomach upset.
• D. Increase your potassium intake while taking this medication.

Correct answer: B

Rationale: The correct answer is B: 'Check your pulse before taking this medication.' When a patient is prescribed digoxin, it is crucial to monitor their pulse rate because digoxin can cause bradycardia (slow heart rate) as a side effect. In contrast, choices A, C, and D are incorrect. Taking digoxin with meals is not necessary; it should be taken consistently at the same time every day. Taking digoxin with an antacid is not recommended as it can interfere with the absorption of the medication. While digoxin can cause hypokalemia (low potassium levels), patients should not increase their potassium intake without healthcare provider guidance to avoid potential complications.

4. A client has deep vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan of care?

• A. Apply cold compresses to the affected extremity.
• B. Massage the affected extremity every 2 hours.
• C. Elevate the affected extremity above the level of the heart.
• D. Keep the affected extremity dependent when sitting.

Correct answer: C

Rationale: The correct intervention for a client with deep vein thrombosis (DVT) is to elevate the affected extremity above the level of the heart. This position promotes venous return, reduces swelling, and helps prevent complications such as pulmonary embolism. Applying cold compresses (choice A) can vasoconstrict blood vessels, potentially worsening the condition. Massaging the affected extremity (choice B) can dislodge the clot and lead to serious complications. Keeping the affected extremity dependent when sitting (choice D) can hinder venous return and exacerbate the DVT.

5. A nurse is caring for a client who has schizophrenia. Which of the following findings should the nurse expect?

• A. Decreased level of consciousness
• B. Inability to identify common objects
• C. Preoccupation with somatic disturbances
• D. Poor problem-solving ability

Correct answer: B

Rationale: The correct answer is B: Inability to identify common objects. Clients with schizophrenia often experience cognitive deficits, such as difficulty in identifying common objects. This can be attributed to impairments in perception and cognition. Choices A, C, and D are not typically associated with schizophrenia. Decreased level of consciousness is more indicative of conditions like head injuries or metabolic disturbances. Preoccupation with somatic disturbances is commonly seen in somatic symptom disorders, not schizophrenia. Poor problem-solving ability is a characteristic of conditions affecting executive functioning like dementia, rather than schizophrenia.

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