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. When is additional Vitamin C not required?

• A. Infancy
• B. Young adulthood
• C. Childhood
• D. Pregnancy

Correct answer: B

Rationale: Vitamin C requirements are increased during infancy, childhood, and pregnancy due to growth and development. However, during young adulthood, the body generally requires a consistent amount of Vitamin C as it is not undergoing rapid growth or physiological changes that necessitate an increase in Vitamin C intake.

3. 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.

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. Before rigor mortis occurs, what is the nurse responsible for?

• A. Providing a complete bath and dressing change
• B. Placing one pillow under the body’s head and shoulders
• C. Removing the body’s clothing and wrapping the body in a shroud
• D. Allowing the body to relax normally

Correct answer: B

Rationale: Before rigor mortis occurs, the nurse is responsible for placing a pillow under the body's head and shoulders. This action helps maintain proper positioning, prevent postmortem changes, and ensure a dignified appearance. Providing a complete bath and dressing change, removing clothing, or wrapping the body in a shroud are tasks typically performed after rigor mortis sets in or later in the postmortem care process. Allowing the body to relax normally does not address the immediate need for proper positioning before rigor mortis occurs.

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