Nursing Elites

1. A nurse is caring for a client who is receiving oxytocin to augment labor. The client has an intrauterine pressure catheter and an internal fetal scalp electrode for monitoring. Which of the following is an indication that the nurse should discontinue the infusion?

• A. Contraction frequency every 3 minutes
• B. Contraction duration of 100 seconds
• C. Fetal heart rate with moderate variability
• D. Fetal heart rate of 118/min

Correct answer: B

Rationale: A contraction duration of 100 seconds indicates potential uterine hyperstimulation, which can lead to fetal distress and decreased uterine perfusion. Prolonged contractions may reduce oxygen supply to the fetus, putting it at risk. Discontinuing the oxytocin infusion is crucial to prevent adverse effects on both the mother and the fetus. The other options do not raise immediate concerns that would necessitate discontinuing the oxytocin infusion. Contraction frequency every 3 minutes is within a normal range. Fetal heart rate with moderate variability and a rate of 118/min are both reassuring signs of fetal well-being.

2. A nurse is caring for a client who has liver cirrhosis and ascites. Which of the following actions should the nurse take to monitor the effectiveness of the treatment?

• A. Measure the client’s abdominal girth daily
• B. Monitor the client’s hemoglobin level
• C. Administer lactulose as prescribed
• D. Weigh the client weekly

Correct answer: A

Rationale: Measuring the client’s abdominal girth daily is the most effective way to monitor the reduction of ascites and fluid retention in clients with liver cirrhosis. This measurement helps assess the effectiveness of treatment in managing ascites by monitoring changes in abdominal size. Monitoring the client’s hemoglobin level (Choice B) is not directly related to assessing the effectiveness of ascites treatment. Administering lactulose as prescribed (Choice C) is important in managing hepatic encephalopathy, not ascites. Weighing the client weekly (Choice D) may not provide real-time feedback on the reduction of ascites compared to daily abdominal girth measurements.

3. A client with preeclampsia is receiving magnesium sulfate. Which finding indicates magnesium toxicity?

• A. Decreased deep tendon reflexes
• B. Increased blood pressure
• C. Tachypnea
• D. Hyperreflexia

Correct answer: A

Rationale: The correct answer is A: Decreased deep tendon reflexes. In a client receiving magnesium sulfate for preeclampsia, decreased deep tendon reflexes indicate magnesium toxicity. Magnesium toxicity can lead to respiratory depression and other serious complications, requiring immediate intervention. Choices B, C, and D are incorrect because increased blood pressure, tachypnea, and hyperreflexia are not typical findings associated with magnesium toxicity.

4. A nurse is caring for a client with diabetes who is experiencing hypoglycemia. Which of the following interventions should the nurse perform first?

• A. Administer insulin
• B. Give the client a carbohydrate snack
• C. Call for assistance
• D. Monitor blood glucose

Correct answer: B

Rationale: The correct answer is to give the client a carbohydrate snack. When a client is experiencing hypoglycemia, the priority intervention is to raise their blood glucose levels quickly. Administering insulin (Choice A) would further lower the blood glucose levels and is contra-indicated in this situation. Calling for assistance (Choice C) may be necessary but is not the priority over addressing the low blood sugar. Monitoring blood glucose (Choice D) is important but not the initial action needed to raise blood glucose levels rapidly.

5. A nurse is planning care for a patient who follows the Mormon belief system. What modifications should the nurse include to meet Mormon dietary practices?

• A. Offer only vegetarian meal options.
• B. Offer non-caffeinated beverage options.
• C. Offer kosher meals.
• D. Limit meat to only fish and poultry.

Correct answer: B

Rationale: The correct answer is B: Offer non-caffeinated beverage options. Mormons avoid caffeinated beverages, so providing non-caffeinated options aligns with their religious practices. Choice A is incorrect because offering only vegetarian meal options is not a specific requirement of the Mormon dietary practices. Choice C is incorrect as kosher meals are associated with Jewish dietary laws, not specific to the Mormon belief system. Choice D is incorrect as limiting meat to only fish and poultry is not a specific dietary requirement for Mormons.

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