Nursing Elites

1. A nurse is assessing a client in active labor. The FHR baseline has been 100/min for 15 minutes. What condition should the nurse suspect?

• A. Maternal fever.
• B. Fetal anemia.
• C. Maternal hypoglycemia.
• D. Chorioamnionitis.

Correct answer: C

Rationale: In this scenario, with a fetal heart rate (FHR) baseline of 100/min for 15 minutes, the nurse should suspect maternal hypoglycemia. Maternal hypoglycemia can result in fetal bradycardia, which is defined as an FHR less than 110 beats per minute. Maternal hypoglycemia requires prompt intervention to prevent adverse outcomes for both the mother and the fetus. Maternal fever (Choice A) typically presents with tachycardia rather than bradycardia in the fetus. Fetal anemia (Choice B) is more likely to present with other signs such as pallor or tachycardia rather than bradycardia. Chorioamnionitis (Choice D) is characterized by maternal fever, uterine tenderness, and foul-smelling amniotic fluid, but it is not directly linked to the FHR baseline being 100/min.

2. When caring for a client with a new prescription for enoxaparin for the prevention of DVT, what is an appropriate action by the nurse?

• A. Expel any air bubbles at the top of the prefilled syringe
• B. Massage the injection site to evenly distribute the medication
• C. Inject the medication into the lateral abdominal wall
• D. Administer an NSAID for injection site discomfort

Correct answer: C

Rationale: When administering enoxaparin for the prevention of DVT, the nurse should inject the medication into the lateral abdominal wall. This site is preferred for subcutaneous injections of enoxaparin to reduce the risk of bleeding or injury. Expelling air bubbles, massaging the injection site, or administering an NSAID for discomfort are not appropriate actions and could lead to complications or ineffective medication delivery.

3. When teaching a client about nutritional intake, what should be included?

• A. Carbohydrates should be at least 45% of your caloric intake.
• B. Protein should be at least 55% of your caloric intake.
• C. Carbohydrates should be at least 30% of your caloric intake.
• D. Protein should be at least 60% of your caloric intake.

Correct answer: A

Rationale: When educating a client about nutritional intake, it is important to mention that carbohydrates should constitute at least 45% of their daily caloric intake for a balanced diet. This macronutrient provides energy and is essential for proper bodily functions. Choice B is incorrect because protein should typically account for around 10-35% of total caloric intake, not 55%. Choice C is too low for the recommended carbohydrate intake, as it should be higher at 45%. Choice D is incorrect as protein intake should generally be around 10-35% of total caloric intake, not 60%.

4. A nurse is providing teaching to a client who has a new prescription for albuterol. Which of the following client statements indicates an understanding of the teaching?

• A. I will use this medication to prevent an asthma attack.
• B. I will use this medication for shortness of breath during an asthma attack.
• C. I will take this medication with my daily vitamins.
• D. I will take this medication at bedtime to prevent an asthma attack.

Correct answer: B

Rationale: The correct answer is B because albuterol is used to treat shortness of breath during an asthma attack. Choice A is incorrect as albuterol is a rescue medication used during an asthma attack, not for prevention. Choice C is incorrect as albuterol should not be taken with daily vitamins. Choice D is incorrect as albuterol is not typically taken at bedtime for asthma prevention.

5. A client with liver cirrhosis is experiencing confusion. Which of the following laboratory values should the nurse report to the provider?

• A. Bilirubin 0.8 mg/dL
• B. Ammonia 145 mcg/dL
• C. Albumin 4 g/dL
• D. Hemoglobin 13.5 g/dL

Correct answer: B

Rationale: The correct answer is B: Ammonia 145 mcg/dL. An elevated ammonia level can indicate hepatic encephalopathy in clients with liver cirrhosis, leading to confusion. Bilirubin (Choice A) is within the normal range, indicating adequate liver function. Albumin (Choice C) and Hemoglobin (Choice D) levels are also within normal limits and are not directly related to the client's confusion in this scenario.

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