Nursing Elites

1. A nurse is caring for a client who is in labor and has an external fetal monitor in place. The nurse observes late decelerations in the fetal heart rate. Which of the following actions should the nurse take first?

• A. Decrease the client's IV fluids
• B. Reposition the client
• C. Administer oxygen by face mask
• D. Document the findings

Correct answer: C

Rationale: Administering oxygen by face mask is the priority intervention when late decelerations are observed in the fetal heart rate. Late decelerations indicate uteroplacental insufficiency, and administering oxygen helps to improve fetal oxygenation. Repositioning the client may also be necessary to relieve pressure on the umbilical cord, but providing oxygen takes precedence to enhance fetal oxygenation. Decreasing IV fluids may not directly address the underlying issue leading to late decelerations. Documenting the findings is important but should not be the first action taken when managing late decelerations.

2. A nurse manager is discussing electronic medical records with a newly licensed nurse. Which of the following actions should the nurse take to maintain client confidentiality?

• A. Log out of the computer terminal before leaving.
• B. Share passwords for computer access with colleagues.
• C. Change computer access passwords on a regular basis.
• D. Avoid accessing information about clients admitted to other units.

Correct answer: A

Rationale: The correct answer is A: Log out of the computer terminal before leaving. Logging out before leaving the computer terminal is crucial to ensuring patient data remains confidential and to prevent unauthorized access. Choice B is incorrect because sharing passwords compromises confidentiality. Choice C is incorrect as changing passwords regularly, although a good practice for security, is not directly related to maintaining client confidentiality. Choice D is incorrect as it does not address the immediate concern of maintaining client confidentiality through proper access to electronic medical records.

3. A patient with heart failure has gained 5 pounds in the last 3 days. What is the nurse's priority intervention?

• A. Restrict the patient's fluid intake.
• B. Monitor the patient's daily weight.
• C. Administer diuretics as prescribed.
• D. Increase the patient's salt intake to promote fluid balance.

Correct answer: B

Rationale: The correct answer is to monitor the patient's daily weight. In heart failure, sudden weight gain indicates fluid retention, which can worsen the condition. Monitoring daily weight helps in early detection of fluid accumulation, allowing timely intervention. Restricting fluid intake (choice A) may be necessary but is not the priority at this point. Administering diuretics (choice C) should be done based on healthcare provider orders, not the nurse's independent decision. Increasing salt intake (choice D) is contraindicated in heart failure as it can exacerbate fluid retention.

4. The nurse is caring for a patient with an incision. Which actions will best indicate an understanding of medical and surgical asepsis for a sterile dressing change?

• A. Donning sterile gown and gloves to remove the wound dressing
• B. Utilizing clean gloves to remove the dressing and clean supplies for the new dressing
• C. Utilizing clean gloves to remove the dressing and sterile supplies for the new dressing
• D. Donning clean goggles, gown, and gloves to dress the wound

Correct answer: C

Rationale: Choice C is the correct answer. When performing a sterile dressing change, it is essential to use clean gloves to remove soiled dressings and sterile gloves and supplies for applying the new dressing. This helps maintain aseptic technique and reduce the risk of introducing pathogens to the wound. Choices A, B, and D involve incorrect use of sterile and clean supplies, which can compromise the sterility of the procedure and increase the risk of infection.

5. A client has a new prescription for clopidogrel. Which of the following instructions should the nurse include?

• A. Take this medication with food
• B. Take this medication three times daily
• C. You might have to stop taking this medication 5 days before any planned surgeries
• D. Expect to have black-colored stools while taking this medication

Correct answer: C

Rationale: The correct answer is C. When instructing a client who is prescribed clopidogrel, the nurse should include information about stopping the medication 5 days before any planned surgeries to reduce the risk of bleeding. This is crucial to prevent excessive bleeding during surgical procedures. Choices A, B, and D are incorrect because taking the medication with food, the frequency of administration, and the possibility of black-colored stools are not specific instructions related to clopidogrel use.

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