Nursing Elites

1. A nurse is assessing a client who is in active labor. The FHR baseline has been 100/min for the past 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, the FHR baseline of 100/min for the past 15 minutes indicates fetal bradycardia, which can be caused by maternal hypoglycemia. Maternal hypoglycemia can lead to decreased oxygen supply to the fetus, resulting in fetal bradycardia. Maternal fever (Choice A) typically presents with tachycardia in the fetus rather than bradycardia. Fetal anemia (Choice B) is more likely to manifest as tachycardia due to compensation for decreased oxygen delivery. Chorioamnionitis (Choice D) may lead to fetal tachycardia as a sign of fetal distress, not bradycardia.

2. What is the appropriate nursing intervention for a patient with suspected deep vein thrombosis (DVT)?

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

Correct answer: A

Rationale: The correct answer is to administer anticoagulants. Anticoagulants help prevent further clot formation in patients with suspected DVT. Encouraging ambulation can be beneficial in preventing DVT but is not the immediate intervention for a suspected case. Compression stockings are more for DVT prevention rather than treatment. Monitoring oxygen saturation is important in assessing respiratory function but is not the primary intervention for suspected DVT.

3. A nurse is assessing a client who has diabetes mellitus and is experiencing hyperglycemia. Which of the following findings should the nurse expect?

• A. Polyuria
• B. Hypoglycemia
• C. Diaphoresis
• D. Tachycardia

Correct answer: A

Rationale: Polyuria is the excessive production of urine and is a common finding in clients with hyperglycemia due to increased glucose levels. High blood sugar levels lead to the body trying to eliminate the excess glucose through urine, resulting in increased urination. Hypoglycemia (choice B) is low blood sugar and is not typically associated with hyperglycemia. Diaphoresis (choice C) is excessive sweating and is not a direct symptom of hyperglycemia. Tachycardia (choice D) is increased heart rate and is not a primary finding in hyperglycemia.

4. A nurse is caring for a client who is receiving a blood transfusion. Which of the following findings is a priority for the nurse to report?

• A. Low back pain
• B. Tachycardia
• C. Flushed skin
• D. Headache

Correct answer: B

Rationale: The correct answer is B: Tachycardia. Tachycardia can indicate a hemolytic transfusion reaction, a severe and life-threatening complication of blood transfusion. The nurse should report tachycardia immediately to prevent further complications. Low back pain, flushed skin, and headache are also important to monitor during a blood transfusion, but they are not as indicative of a severe transfusion reaction as tachycardia.

5. A client with COPD is receiving discharge teaching. Which statement indicates an understanding of the teaching?

• A. I will avoid breathing deeply while using my incentive spirometer.
• B. I will limit my fluid intake to 1 liter per day.
• C. I will exercise in an area that is humid.
• D. I will use pursed-lip breathing techniques.

Correct answer: D

Rationale: The correct answer is D. Using pursed-lip breathing techniques is beneficial for clients with COPD as it helps control shortness of breath by keeping airways open longer. Option A is incorrect as deep breathing while using an incentive spirometer is essential to prevent complications such as atelectasis. Option B is incorrect because limiting fluid intake to 1 liter per day is not a standard recommendation for clients with COPD. Option C is incorrect as exercising in a humid area can exacerbate breathing difficulties for clients with COPD.

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