Nursing Elites

1. A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations of the FHR. Which of the following actions should the nurse take first?

• A. Prepare the equipment necessary to initiate an amnioinfusion
• B. Administer oxygen at 10 L/min via a non-rebreather face mask
• C. Discontinue the infusion of oxytocin
• D. Place the client in a left lateral position

Correct answer: C

Rationale: The correct first action for the nurse to take is to discontinue the infusion of oxytocin. Oxytocin can lead to uterine hyperstimulation and fetal distress, contributing to variable decelerations in fetal heart rate. By stopping the oxytocin infusion, the nurse can promptly assess and manage the fetal heart rate. Choice A, preparing for amnioinfusion, is not the priority when faced with recurrent variable decelerations. Choice B, administering oxygen, is important but addressing the oxytocin infusion issue takes precedence. Choice D, placing the client in a left lateral position, is beneficial for optimizing fetal oxygenation but discontinuing oxytocin is the initial step in managing variable decelerations.

2. A charge nurse discovers that a nurse did not notify the provider that a client's condition had changed. The charge nurse should identify that the nurse is accountable for which of the following torts?

• A. Assault
• B. Battery
• C. Negligence
• D. False imprisonment

Correct answer: C

Rationale: The correct answer is C: Negligence. Negligence refers to the failure to take reasonable care or fulfill a duty, which can cause harm to others. In this scenario, the nurse's failure to notify the provider of a change in the client's condition constitutes negligence as it breaches the standard of care expected in healthcare practice. Choice A, Assault, involves the threat of harmful or offensive contact, which is not applicable in this situation. Choice B, Battery, refers to the intentional harmful or offensive touching of another person without their consent, which is also not relevant here. Choice D, False imprisonment, involves the intentional confinement or restraint of an individual against their will, which is not the issue described in the scenario. Therefore, the most appropriate tort in this case is negligence.

3. A nurse is planning discharge teaching for cord care for the parent of a newborn. Which instructions would you include in the teaching?

• A. Contact provider if the cord turns black
• B. Clean the base of the cord with hydrogen peroxide daily
• C. Keep the cord dry until it falls off
• D. The cord stump will fall off in ten days

Correct answer: C

Rationale: The correct instruction to include in the teaching for cord care is to keep the cord dry until it falls off naturally. This helps prevent infection, as the cord typically falls off in 10-14 days, not within five days. Instructing the parent to contact the provider if the cord turns black (Choice A) is important to monitor for signs of infection. Cleaning the base of the cord with hydrogen peroxide daily (Choice B) is not recommended as it can delay healing. Stating that the cord stump will fall off in ten days (Choice D) provides a more accurate timeframe compared to the initial estimation of five days.

4. A client is being taught how to use crutches by a nurse. Which of the following instructions should the nurse include?

• A. Place weight on the underarms.
• B. Keep the elbows extended when walking.
• C. Support your weight on your hands.
• D. Hold the crutches 10 cm in front of you when standing.

Correct answer: C

Rationale: The correct answer is C: 'Support your weight on your hands.' When using crutches, it is important to support your weight on your hands rather than underarms to prevent injury to the axillary nerves and blood vessels. Placing weight on the underarms can lead to nerve damage and circulatory issues. Choices A, B, and D are incorrect. Keeping the elbows extended when walking is important for stability, holding the crutches slightly in front of you allows for proper balance, and supporting weight on the hands maintains the correct weight-bearing position.

5. A nurse is assessing a client for signs of allergic reaction. Which of the following should the nurse look for?

• A. Fever
• B. Rash
• C. Fatigue
• D. Increased appetite

Correct answer: B

Rationale: Correct! When assessing a client for signs of an allergic reaction, a nurse should look for a rash. A rash is a common manifestation of an allergic response, such as contact dermatitis or hives. It is important to recognize and assess rashes promptly as they can indicate an allergic reaction.\nOption A, fever, is not typically a primary sign of an allergic reaction but may occur in severe cases. Option C, fatigue, is a general symptom and not specific to allergic reactions. Option D, increased appetite, is not a common sign of an allergic reaction and is more likely related to other conditions or factors.

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