Nursing Elites

1. A client in labor is receiving oxytocin. Which of the following findings indicates that the nurse should increase the rate of infusion?

• A. Urine output of 20 ml/hr.
• B. Montevideo units constantly at 300 mm Hg.
• C. FHR pattern showing absent variability.
• D. Contractions occurring every 5 minutes and lasting 30 seconds.

Correct answer: B

Rationale: Montevideo units measure the strength and frequency of contractions during labor. A consistent Montevideo units reading of 300 mm Hg or higher is indicative of effective uterine contractions. In this scenario, an increase in the rate of oxytocin infusion may be warranted to further augment contractions and promote progress in labor. The other options, such as low urine output, absent variability in fetal heart rate, and short contractions, do not directly correlate with the need for an increase in oxytocin infusion rate.

2. A healthcare provider is caring for a group of clients. Which of the following clients is not at risk for pulmonary embolism?

• A. A client who has a BMI of 30
• B. A female client who is postmenopausal
• C. A client who has a fractured femur
• D. A client who has chronic atrial fibrillation

Correct answer: B

Rationale: Postmenopausal status is not a significant risk factor for pulmonary embolism. Risk factors for pulmonary embolism include obesity (BMI of 30 or higher), immobility such as having a fractured femur, and conditions like chronic atrial fibrillation that increase the risk of blood clot formation. While postmenopausal status may be associated with other health risks, it is not directly linked to an increased risk of pulmonary embolism.

3. When removing a contaminated gown, what should be the first thing touched by the nurse?

• A. Waist tie and neck tie at the back of the gown
• B. Waist tie in front of the gown
• C. Cuffs of the gown
• D. Inside of the gown

Correct answer: A

Rationale: When removing a contaminated gown, the nurse should ensure the first thing touched is the waist tie and neck tie at the back of the gown. This procedure helps prevent contamination by ensuring that the outer surface of the gown, which is likely to be contaminated, is not touched during removal. By touching the back ties first, the nurse minimizes the risk of transferring any contaminants to themselves or the environment.

4. The correct method for determining the vastus lateralis site for I.M. injection is to:

• A. Locate the upper aspect of the upper outer quadrant of the buttock about 5 to 8 cm below the iliac crest
• B. Palpate the lower edge of the acromion process and the midpoint lateral aspect of the arm
• C. Palpate a 1” circular area anterior to the umbilicus
• D. Divide the area between the greater femoral trochanter and the lateral femoral condyle into thirds, and select the middle third on the anterior of the thigh

Correct answer: D

Rationale: The vastus lateralis site is located in the middle third of the thigh.

5. How can preserving skin integrity impact the circular chain of infection?

• A. Host
• B. Reservoir
• C. Mode of transmission
• D. Portal of entry

Correct answer: D

Rationale: Preserving skin integrity plays a key role in breaking the chain of infection by eliminating the portal of entry for pathogens. When the skin is intact, it acts as a natural barrier that prevents pathogens from entering the body. By maintaining skin integrity through proper hygiene and wound care, the risk of infection is significantly reduced, disrupting the cycle of infection transmission.

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