Nursing Elites

1. A woman is in the active phase of labor. An external monitor has been applied, and a fetal heart deceleration of uniform shape is observed, beginning just as the contraction is underway and returning to the baseline at the end of the contraction. Which of the following nursing actions is most appropriate?

• A. Administer O2 if necessary.
• B. Turn the client on her left side.
• C. Notify the physician.
• D. No action is necessary.

Correct answer: D

Rationale: The correct answer is 'No action is necessary.' In this scenario, the fetal heart deceleration of uniform shape observed is an early deceleration resulting from head compression. Early decelerations are benign and typically do not require any intervention as they mirror the contraction pattern. It is essential to closely observe both the mother and the baby. Administering O2 (Choice A) is not necessary as early decelerations do not indicate fetal distress. Turning the client on her left side (Choice B) is not required for early decelerations. Notifying the physician (Choice C) is not needed for this type of deceleration, as it is a normal response to head compression during labor.

2. A client is admitted to telemetry with a diagnosis of diabetes at 3pm. At 10pm, the client is unresponsive. BP is 98/64, Resp 38, HR 100, T 97. The nurse notes a fruity smell on the client's breath. The nurse recognizes that the client is in which acid-base imbalance?

• A. Respiratory acidosis
• B. Respiratory alkalosis
• C. Metabolic acidosis
• D. Metabolic alkalosis

Correct answer: C

Rationale: Based on the client's unresponsiveness, fruity breath smell, and the presence of diabetes, the nurse can infer that the client is experiencing diabetic ketoacidosis (DKA). DKA is a complication of diabetes characterized by the accumulation of ketones in the body, leading to metabolic acidosis. The fruity breath smell is due to the presence of ketones. Therefore, the correct acid-base imbalance in this scenario is metabolic acidosis. Choice A, respiratory acidosis, is incorrect because the scenario does not provide evidence of primary respiratory dysfunction. Choice B, respiratory alkalosis, is incorrect as the client's condition does not align with the typical causes and symptoms of respiratory alkalosis. Choice D, metabolic alkalosis, is incorrect as the symptoms and history provided do not suggest a state of metabolic alkalosis.

3. A 14-year-old boy has been admitted to a mental health unit for observation and treatment. The boy becomes agitated and starts yelling at nursing staff members. What should the nurse's first response be?

• A. Create an atmosphere of seclusion for the boy according to procedures.
• B. Remove other patients from the area for added safety.
• C. Ask the patient, "What is making you mad?"?
• D. Ask the patient, "Why are you behaving this way? Have you thought about what may help you calm down?"?

Correct answer: A

Rationale: In a situation where a patient is agitated and yelling, the first response should be to create an atmosphere of seclusion for the safety of the patient and others. Seclusion is a standard procedure to help manage aggressive behaviors and prevent harm. Options B, C, and D are not appropriate in this scenario. Removing other patients may not address the immediate safety concern, asking the patient what is making them mad can escalate the situation, and questioning why the patient is behaving that way may not help in managing the current agitation. Therefore, seclusion is the recommended course of action in this scenario to ensure the safety and well-being of all involved.

4. What is an appropriate intervention for the client with suspected genitourinary trauma and visible blood at the urethral meatus?

• A. Insertion of a Foley catheter.
• B. Performing an in-and-out catheter specimen for urinalysis.
• C. Obtaining a voided urine specimen for urinalysis.
• D. Ordering a urinalysis by the physician.

Correct answer: D

Rationale: When a client presents with suspected genitourinary trauma and visible blood at the urethral meatus, obtaining a voided urine specimen for urinalysis is an appropriate intervention. This helps assess for any urinary tract injuries or abnormalities without further traumatizing the area. Insertion of a Foley catheter (Choice A) should be avoided as it can worsen the existing trauma. Performing an in-and-out catheter specimen (Choice B) involves unnecessary manipulation and can increase the risk of complications. Ordering a urinalysis by the physician (Choice D) may delay the assessment compared to obtaining a direct voided urine specimen.

5. A 28-year-old male has a diagnosis of AIDS. The patient has had a two-year history of AIDS. The most likely cognitive deficits include which of the following?

• A. Disorientation
• B. Sensory changes
• C. Inability to produce sound
• D. Hearing deficits

Correct answer: A

Rationale: In individuals with AIDS, cognitive deficits commonly manifest as confusion and disorientation, making choice A, 'Disorientation,' the correct answer. Sensory changes (choice B) and hearing deficits (choice D) are more related to sensory processing rather than cognitive impairment. 'Inability to produce sound' (choice C) is more indicative of a speech or language deficit rather than a cognitive impairment typically seen in AIDS patients.

Similar Questions