Nursing Elites

1. All of the following interventions should be performed when fetal heart monitoring indicates fetal distress except:

• A. Increase maternal fluids.
• B. Administer oxygen.
• C. Decrease maternal fluids.
• D. Turn the mother.

Correct answer: C

Rationale: When fetal heart monitoring indicates fetal distress, interventions are aimed at improving oxygenation to the fetus. Increasing maternal fluids helps improve placental perfusion and oxygen delivery to the fetus. Administering oxygen also aids in increasing oxygen supply to the fetus. Turning the mother can help relieve pressure on the vena cava, optimizing blood flow to the placenta. Therefore, decreasing maternal fluids would not be performed as it can further compromise placental perfusion and fetal oxygenation, making it the exception. Decreasing maternal fluids could potentially exacerbate fetal distress by reducing oxygen delivery and nutrient supply to the fetus, which is contrary to the goal of managing fetal distress.

2. A nurse enters a client's room to administer a medication that has been prescribed by the health care provider. The client asks the nurse about the medication. Which response by the nurse is appropriate?

• A. 'I know that it's for fluid buildup, and I think you've taken it before.''
• B. 'It's called furosemide (Lasix), and it will promote urination and rid your body of the excess fluid. It can cause an alteration in electrolyte levels, so we'll need to increase the potassium in your diet.''
• C. 'It's to help get rid of the swelling in your feet.''
• D. ''You need to discuss this medication with your health care provider.''

Correct answer: B

Rationale: A client has the right to be informed of the medication name, purpose, action, and potential undesirable effects of a prescribed medication. The nurse should provide adequate information to the client. Choice B is the correct answer as it includes the medication name, its purpose (promoting urination and eliminating excess fluid), and a potential side effect (alteration in electrolyte levels) with a plan for managing it (increasing potassium in the diet). This response demonstrates thorough and complete information. Choice A provides some information but lacks details on potential side effects and dietary adjustments. Choice C is vague and does not provide specific details about the medication. Choice D deflects the client's question and does not fulfill the client's right to information.

3. How is the information documented on incident reports used?

• A. to analyze risk categories
• B. to ensure compliance with regulations
• C. to identify staff's educational needs
• D. all of the above

Correct answer: D

Rationale: The information documented on incident reports is used for various purposes, including analyzing risk categories, ensuring compliance with regulations, and identifying staff's educational needs. Incident reports provide valuable data that can be utilized in risk management, quality monitoring, and improvement programs. Therefore, the correct answer is 'all of the above.' Choices A, B, and C are all correct as incident reports are used for analyzing risk categories, ensuring compliance with regulations, and identifying staff's educational needs, respectively. Thus, the most comprehensive answer is 'all of the above.'

4. The LPN is caring for a 32-year-old female client who is 8 hours post-op after a tonsillectomy. Which of these actions would be appropriate for the nurse to take?

• A. Inform the client that ear pain may occur and is normal.
• B. Provide ice water and a straw to promote easy fluid consumption.
• C. Provide hot tea to soothe the throat.
• D. Monitor vitals every 15 minutes.

Correct answer: A

Rationale: The appropriate action for the nurse to take is to inform the client that ear pain may occur and is normal after a tonsillectomy. Referred pain in the ear is common due to related nerve pathways. It is essential to educate the client about this to alleviate concerns. Providing ice water and a straw is not recommended as they may irritate the throat and disturb the healing process. Hot beverages like tea should also be avoided for the same reason. While monitoring vitals every 15 minutes is crucial in the immediate postoperative period for early identification of any complications, it is not the most appropriate action in this scenario where addressing the client's concerns and providing education is key.

5. Which of the following neurological disorders is characterized by writhing, twisting movements of the face and limbs?

• A. epilepsy
• B. Parkinson's
• C. multiple sclerosis
• D. Huntington's chorea

Correct answer: D

Rationale: Huntington's chorea is a neurological disorder characterized by writhing, twisting movements of the face and limbs, known as chorea. Epilepsy is characterized by seizures, not writhing, twisting movements. Parkinson's disease presents with tremors, rigidity, and bradykinesia, not writhing, twisting movements. Multiple sclerosis affects the central nervous system but does not typically involve writhing, twisting movements. Therefore, the correct answer is Huntington's chorea as it specifically manifests with these characteristic movements.

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