Nursing Elites

1. What is the transparent membrane that focuses the light entering the eyes onto the retina?

• A. Lens
• B. Sclera
• C. Cornea
• D. Pupils

Correct answer: A

Rationale: The correct answer is the lens. The lens is a transparent structure in the eye that helps to focus light onto the retina, which is essential for clear vision. The cornea and sclera are also important parts of the eye, but the lens specifically plays a crucial role in focusing light onto the retina. The sclera is the white outer layer of the eye that helps maintain the shape of the eye, while the cornea is the clear outer covering of the eye that helps to refract light into the eye.

2. A client who is at 38 weeks gestation, is in active labor, and has ruptured membranes is being cared for by a nurse. What action should the nurse take?

• A. Insert an indwelling urinary catheter
• B. Apply fetal heart rate monitor
• C. Initiate fundal massage
• D. Initiate an oxytocin IV infusion

Correct answer: B

Rationale: When caring for a client in active labor with ruptured membranes, the priority action for the nurse is to apply a fetal heart rate monitor. This helps monitor the well-being of the fetus during labor and delivery, enabling timely interventions if any fetal distress is detected. Inserting an indwelling urinary catheter may be required in some cases, but it is not the priority in the given scenario. Fundal massage is typically done after delivery to help the uterus contract and prevent postpartum hemorrhage. Initiating an oxytocin IV infusion may be indicated to augment labor, but it is not the initial action needed in this situation.

3. The healthcare professional is preparing to take vital signs in an alert client admitted to the hospital with dehydration secondary to vomiting and diarrhea. What is the best method used to assess the client’s temperature?

• A. Oral
• B. Axillary
• C. Radial
• D. Heat-sensitive tape

Correct answer: A

Rationale: The most accurate method for assessing temperature in an alert client is the oral method. It provides a more reliable reflection of the body's core temperature compared to axillary or radial methods. In cases of dehydration, it is important to get an accurate temperature reading to monitor the client's condition closely. Axillary temperature may be affected by environmental factors, while radial temperature measurement is not a standard method for assessing core body temperature. Heat-sensitive tape is not a recognized method for assessing body temperature in clinical practice.

4. A client in labor is receiving oxytocin. Which of the following findings indicates that the nurse should increase the rate of infusion?

• A. Urine output of 20 ml/hr.
• B. Montevideo units constantly at 300 mm Hg.
• C. FHR pattern showing absent variability.
• D. Contractions occurring every 5 minutes and lasting 30 seconds.

Correct answer: B

Rationale: Montevideo units measure the strength and frequency of contractions during labor. A consistent Montevideo units reading of 300 mm Hg or higher is indicative of effective uterine contractions. In this scenario, an increase in the rate of oxytocin infusion may be warranted to further augment contractions and promote progress in labor. The other options, such as low urine output, absent variability in fetal heart rate, and short contractions, do not directly correlate with the need for an increase in oxytocin infusion rate.

5. Which of the following is included in Orem’s theory?

• A. Maintenance of a sufficient intake of air
• B. Self-perception
• C. Love and belonging
• D. Physiological needs

Correct answer: A

Rationale: Orem's theory, also known as the Self-Care Deficit Nursing Theory, focuses on individuals' ability to perform self-care to maintain health and well-being. One specific component of this theory is the maintenance of a sufficient intake of air, which is crucial for sustaining life and overall health. Option A is the correct choice as it directly relates to meeting physiological needs, such as the intake of air, to support optimal functioning and health. Choices B, C, and D are incorrect as they do not specifically align with Orem's emphasis on self-care and meeting physiological requirements.

Similar Questions