Nursing Elites

1. What is the nurse's next action after a laboring client's membranes have just ruptured?

• A. Assess fetal heart rate pattern
• B. Monitor uterine contractions
• C. Administer oxygen
• D. Prepare for delivery

Correct answer: A

Rationale: After a laboring client's membranes have ruptured, the nurse's immediate priority is to assess the fetal heart rate pattern. This assessment is crucial to ensure the fetus is not in distress, especially to rule out umbilical cord compression that could affect blood flow to the fetus. While monitoring uterine contractions is important, assessing the fetal heart rate takes precedence in this situation as it directly reflects the fetus's well-being. Administering oxygen may be necessary later depending on the fetal status, and preparing for delivery should only occur if the assessment indicates fetal distress or other complications. Therefore, the correct next action for the nurse is to assess the fetal heart rate pattern.

2. A client receiving chemotherapy is experiencing neutropenia. Which of the following should the nurse include in this client's education?

• A. Track oral temperature weekly
• B. Gardening is a good form of mild exercise
• C. Avoid crowded events
• D. Eat plenty of fresh fruits and vegetables

Correct answer: C

Rationale: Clients with neutropenia have a weakened immune system, making them susceptible to infections. Avoiding crowded events helps reduce the risk of exposure to pathogens, thereby minimizing the chance of infections. Tracking oral temperature is important for detecting fever early, which is a sign of infection and requires immediate medical attention. While gardening can be a good form of exercise, clients with neutropenia should avoid it due to the risk of exposure to bacteria and fungi present in soil. Eating fresh fruits and vegetables is generally encouraged for overall health but may carry a risk of bacterial contamination, which could be harmful to a client with neutropenia.

3. When teaching a client about the use of lisinopril, which of the following should be included?

• A. It can cause a persistent cough
• B. It is a calcium channel blocker
• C. It is safe during pregnancy
• D. It should be taken with food

Correct answer: A

Rationale: The correct answer is A. Lisinopril is an ACE inhibitor, and a common side effect associated with its use is a persistent cough. This is important information that the client should be aware of. Choice B is incorrect because lisinopril is not a calcium channel blocker, it is an ACE inhibitor. Choice C is incorrect as lisinopril is not considered safe during pregnancy, especially during the second and third trimesters as it can cause harm to the fetus. Choice D is incorrect because lisinopril is typically recommended to be taken on an empty stomach, about an hour before meals.

4. A client is receiving magnesium sulfate for preeclampsia. Which finding indicates magnesium toxicity?

• A. Respiratory rate of 12/min
• B. Diminished deep tendon reflexes
• C. Urine output 40 mL/hr
• D. Systolic blood pressure of 140 mm Hg

Correct answer: B

Rationale: Diminished deep tendon reflexes are a sign of magnesium toxicity. Magnesium sulfate can depress the central nervous system, leading to decreased reflexes. Respiratory rate of 12/min, urine output 40 mL/hr, and systolic blood pressure of 140 mm Hg are not specific findings of magnesium toxicity. Respiratory depression, oliguria, and hypotension are more concerning signs that require immediate attention.

5. A nurse is planning a staff education program to review nursing interventions for patients who have kidney failure. What source should the nurse identify as the best source for obtaining evidence-based practice information?

• A. A recent peer-reviewed nursing research article
• B. A website for a nursing association
• C. A textbook published 5 years ago
• D. An expert opinion from a seasoned nurse

Correct answer: A

Rationale: The correct answer is A: A recent peer-reviewed nursing research article. Peer-reviewed research articles provide the most current and reliable evidence-based practice information for clinical care. Choice B, a website for a nursing association, may have valuable information but may not always guarantee the highest level of evidence. Choice C, a textbook published 5 years ago, may not reflect the most up-to-date practices and guidelines. Choice D, an expert opinion from a seasoned nurse, though valuable, is not as reliable as evidence derived from peer-reviewed research articles.

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