Nursing Elites

1. A nurse is assessing a client who is in active labor and notes the FHR baseline has been 100/min for the past 15 minutes. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia?

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

Correct answer: C

Rationale: In this scenario, the fetal heart rate (FHR) baseline of 100/min for the past 15 minutes indicates bradycardia. Maternal hypoglycemia can lead to decreased oxygen supply to the fetus, resulting in fetal bradycardia. This situation requires immediate intervention to address the underlying cause. Choices A, B, and D are incorrect as they are not typically associated with fetal bradycardia. Maternal fever, fetal anemia, and chorioamnionitis may have other effects on the fetus but are not primary causes of bradycardia in this context.

2. A healthcare provider is caring for a client who has been diagnosed with sepsis. Which of the following laboratory results indicates that the client is developing disseminated intravascular coagulation (DIC)?

• A. Elevated hemoglobin
• B. Elevated white blood cell count
• C. Decreased fibrinogen level
• D. Decreased platelet count

Correct answer: D

Rationale: The correct answer is D, decreased platelet count. In disseminated intravascular coagulation (DIC), there is widespread activation of clotting factors leading to the formation of multiple blood clots throughout the body, which can deplete platelets. A decreased platelet count is a hallmark of DIC. Elevated hemoglobin (choice A) and elevated white blood cell count (choice B) are not specific indicators of DIC. While fibrinogen levels (choice C) can be decreased in DIC due to consumption, a decreased platelet count is a more specific and early sign of DIC development.

3. What is the best intervention for a patient with constipation?

• A. Administer a stool softener
• B. Encourage fluid intake
• C. Provide a high-fiber diet
• D. Administer a laxative

Correct answer: B

Rationale: Encouraging fluid intake is the best intervention for a patient with constipation. Fluids help soften stools, making them easier to pass. While stool softeners and laxatives can also help with constipation, they are more of a short-term solution and may not address the root cause. A high-fiber diet is beneficial for preventing constipation in the long run, but in the immediate situation of constipation, fluid intake is key.

4. When using an IV pump for a newly admitted client, what action should the nurse take?

• A. Grasp the IV pump cord when unplugging it from the electrical outlet.
• B. Ensure the pump is plugged into an outlet with two prongs.
• C. Hold the IV pump cord while walking the client.
• D. Check for malfunctioning pump alerts.

Correct answer: C

Rationale: The correct action for the nurse to take when using an IV pump for a newly admitted client is to hold the IV pump cord while walking the client. This is important for ensuring the safe and secure management of the IV pump during client mobility. Option A is incorrect as grasping the IV pump cord when unplugging it can lead to electrical hazards. Option B is incorrect as ensuring the pump is plugged into an outlet with two prongs is important for electrical safety but not directly related to the nurse's action. Option D is also important but does not directly address the nurse's immediate action while using the IV pump with the client.

5. What is the priority intervention for a patient with a severe allergic reaction?

• A. Administer epinephrine
• B. Administer corticosteroids
• C. Administer oxygen
• D. Administer antihistamines

Correct answer: A

Rationale: The correct answer is to administer epinephrine. Epinephrine is the first-line treatment for severe allergic reactions because it rapidly reverses the symptoms of anaphylaxis by constricting blood vessels, increasing heart rate, and relaxing airway muscles. Corticosteroids, although helpful to reduce inflammation, are not the priority in the acute management of severe allergic reactions. Oxygen may be needed to support breathing, but it is not the initial priority. Antihistamines are not as effective as epinephrine in treating severe allergic reactions and should not be the first intervention.

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