Nursing Elites

1. A nurse is caring for a client who is receiving oxytocin to augment labor. The client's contractions are occurring every 90 seconds with a duration of 90 seconds. Which of the following actions should the nurse take?

• A. Increase oxytocin infusion.
• B. Decrease oxytocin infusion.
• C. Maintain oxytocin infusion.
• D. Discontinue oxytocin infusion.

Correct answer: D

Rationale: The correct action for the nurse to take in this scenario is to discontinue the oxytocin infusion. With contractions occurring every 90 seconds with a duration of 90 seconds, the contractions are too frequent and prolonged, which can lead to uterine rupture or fetal distress. Increasing or maintaining the oxytocin infusion would exacerbate the situation, potentially causing harm to the mother and fetus. Decreasing the oxytocin infusion might not be sufficient to address the issue, making discontinuation the most appropriate action to ensure the safety of both the client and the baby.

2. When providing dietary teaching for a new prescription of phenelzine, which of the following foods should be avoided?

• A. Broccoli
• B. Yogurt
• C. Cream Cheese
• D. Fruit Juice

Correct answer: A

Rationale: The correct answer is A, Broccoli. Foods high in tyramine, such as broccoli, should be avoided when taking MAOIs like phenelzine to prevent a hypertensive crisis. Yogurt, cream cheese, and fruit juice do not contain significant levels of tyramine and can be safely consumed while on phenelzine.

3. A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse include?

• A. Remove the client's restraint every 4 hours.
• B. Document the client's condition every 15 minutes.
• C. Attach the restraint to the bed's side rails.
• D. Request a PRN restraint prescription for clients who are aggressive.

Correct answer: B

Rationale: The correct answer is B. When updating protocols for the use of belt restraints, it is essential to document the client's condition every 15 minutes. This frequent documentation helps ensure the client's safety and allows for timely assessment of the need for continued restraint use. Choice A is incorrect because restraints should be removed and reassessed more frequently than every 4 hours. Choice C is incorrect as restraints should not be attached to the bed's side rails due to entrapment risks. Choice D is also incorrect as restraints should not be used as needed (PRN) but rather based on a specific prescription and assessment indicating the need for restraint use.

4. How should signs of infection in a post-surgical patient be assessed?

• A. Check the surgical site
• B. Check the patient's vital signs
• C. Monitor for fever
• D. Check for abnormal breath sounds

Correct answer: A

Rationale: Assessing the surgical site is crucial in identifying early signs of infection post-surgery. Changes such as redness, swelling, warmth, or drainage may indicate an infection developing. While monitoring vital signs and fever are important in infection assessment, they are general indicators and may not show localized signs at the surgical site. Checking for abnormal breath sounds is more relevant when assessing respiratory issues rather than infection at the surgical site.

5. A nurse is assessing a client who is receiving enteral nutrition via a nasogastric tube. Which of the following findings should the nurse report to the provider?

• A. Gastric pH of 2.5.
• B. Bowel sounds every 4 hours.
• C. Diarrhea of 250 mL in 24 hours.
• D. Gastric residual of 150 mL.

Correct answer: D

Rationale: A gastric residual of 150 mL may indicate delayed gastric emptying and should be reported to the provider.

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