Nursing Elites

1. A client who is at 38 weeks gestation, is in active labor, and has ruptured membranes is being cared for by a nurse. What action should the nurse take?

• A. Insert an indwelling urinary catheter
• B. Apply fetal heart rate monitor
• C. Initiate fundal massage
• D. Initiate an oxytocin IV infusion

Correct answer: B

Rationale: When caring for a client in active labor with ruptured membranes, the priority action for the nurse is to apply a fetal heart rate monitor. This helps monitor the well-being of the fetus during labor and delivery, enabling timely interventions if any fetal distress is detected. Inserting an indwelling urinary catheter may be required in some cases, but it is not the priority in the given scenario. Fundal massage is typically done after delivery to help the uterus contract and prevent postpartum hemorrhage. Initiating an oxytocin IV infusion may be indicated to augment labor, but it is not the initial action needed in this situation.

2. A client with COPD expresses concerns about leaving the house due to continuous oxygen use. What is an appropriate response by the nurse?

• A. There are portable oxygen delivery systems that you can take with you.
• B. When you go out, you can remove the oxygen and then reapply it when you get home.
• C. You probably will not be able to go out as much as you used to.
• D. Home health services will come to see you so you will not need to get out.

Correct answer: A

Rationale: For a client with COPD concerned about leaving the house while on continuous oxygen, the nurse should provide reassurance by mentioning the availability of portable oxygen delivery systems. These systems allow the client to maintain their oxygen therapy while being mobile, enabling them to go out and engage in activities outside the home. This response promotes independence and quality of life for the client, addressing their immediate concerns and offering a practical solution to their perceived limitation.

3. A healthcare professional is reviewing the health records of five clients. Which of the following clients is not at risk for developing acute respiratory distress syndrome?

• A. A client who experienced a near-drowning incident
• B. A client following coronary artery bypass graft surgery
• C. A client who has a hemoglobin of 15.1 g/dL
• D. A client who has dysphagia

Correct answer: C

Rationale: Acute respiratory distress syndrome (ARDS) is a severe lung condition that can be triggered by various factors such as near-drowning incidents, surgeries like coronary artery bypass graft, and underlying conditions like dysphagia. Hemoglobin levels do not directly influence the risk of developing ARDS. A hemoglobin level of 15.1 g/dL falls within the normal range and does not predispose an individual to ARDS.

4. A nurse obtained a client’s pulse and found the rate to be above normal. The nurse documents this finding as:

• A. Tachypnea
• B. Hyperpyrexia
• C. Arrhythmia
• D. Tachycardia

Correct answer: D

Rationale: When a nurse finds a client's pulse rate to be above normal, it is documented as tachycardia. Tachycardia specifically refers to an elevated heart rate, while tachypnea is rapid breathing, hyperpyrexia is high fever, and arrhythmia is an irregular heartbeat. Therefore, the correct term to describe an above-normal pulse rate is tachycardia.

5. When is the most appropriate time for obtaining a sputum specimen for culture?

• A. Early in the morning
• B. After the patient eats a light breakfast
• C. After aerosol therapy
• D. After chest physiotherapy

Correct answer: A

Rationale: Obtaining a sputum specimen early in the morning is the most appropriate time because secretions have accumulated overnight. This timing provides the best sample with the least contamination, leading to more accurate culture results and aiding in diagnosing respiratory infections effectively.

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