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. In Maslow’s hierarchy of physiological needs, the human need of greatest priority is:

• A. Love
• B. Elimination
• C. Nutrition
• D. Oxygen

Correct answer: D

Rationale: In Maslow’s hierarchy of physiological needs, the most basic and immediate need is physiological survival, which includes the need for oxygen. Without oxygen, the body cannot survive for more than a few minutes, making it the highest priority physiological need according to Maslow's hierarchy.

3. A healthcare professional is providing information about tuberculosis to a group of clients at a local community center. Which of the following manifestations should the professional NOT include in the teaching?

• A. Persistent cough
• B. Weight gain
• C. Fatigue
• D. Night sweats

Correct answer: B

Rationale: Weight gain is not a typical manifestation of tuberculosis. The characteristic symptoms of tuberculosis include a persistent cough, fatigue, and night sweats. Weight loss, not weight gain, is a common symptom associated with tuberculosis due to the impact of the infection on the body's metabolism. Therefore, the healthcare professional should exclude weight gain from the teaching on tuberculosis manifestations.

4. 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.

5. When caring for a client on pressure support ventilation (PSV), which statement by the nurse indicates an understanding of PSV?

• A. It keeps the alveoli open and prevents atelectasis.
• B. It allows preset pressure delivered during spontaneous ventilation.
• C. It guarantees minimal minute ventilator.
• D. It delivers a preset ventilatory rate and tidal volume to the client.

Correct answer: B

Rationale: Pressure support ventilation (PSV) is a mode that delivers a preset pressure when the client initiates a breath. This support helps the client to breathe spontaneously by reducing the work of breathing. The correct statement indicating an understanding of PSV is that it allows preset pressure to be delivered during spontaneous ventilation, as it assists the client's efforts without controlling the rate or volume of each breath.

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