Nursing Elites

1. A client is admitted to the postpartum unit and tells the nurse she had rheumatic fever as a child, which resulted in some 'heart damage'. The nurse knows that this client is at particular risk for developing heart failure during the immediate postpartum period. Based on the client's history, which nursing problem has the highest priority?

• A. Nausea and vomiting.
• B. Risk for infection.
• C. Sleep deprivation.
• D. Fluid volume excess.

Correct answer: D

Rationale: Fluid volume excess is a priority concern in this client, as heart damage from rheumatic fever can impair the heart's ability to manage increased blood volume postpartum, leading to potential heart failure. Monitoring and managing fluid volume status are crucial to prevent complications in this high-risk client. Choices A, B, and C are not the highest priority in this situation. Nausea and vomiting, risk for infection, and sleep deprivation are important but do not pose an immediate threat to the client's physiologic stability compared to the risk of heart failure due to fluid volume excess.

2. The healthcare provider prescribes oxytocin 2 milliunits/minute to induce labor for a client at 41-weeks gestation. The nurse initiates an infusion of Ringer’s Lactate solution 1000 mL with oxytocin 10 units. How many mL/hour should the nurse program the infusion pump?

• A. 12 mL/hour
• B. 2 mL/hour
• C. 22 mL/hour
• D. 42 mL/hour

Correct answer: A

Rationale: To calculate the infusion rate in mL/hour, first, convert 2 milliunits/minute to milliunits/hour by multiplying by 60 to get 120 milliunits/hour. Then, calculate the mL/hour using the formula: milliunits/hour (120) × total volume (1000 mL) ÷ units in IV solution (10 units) = 1200 mL/hour. Therefore, the nurse should program the infusion pump to deliver 12 mL/hour to provide the prescribed dose of oxytocin. Choice B is incorrect as it does not reflect the correct calculation. Choice C is incorrect as it is not derived from the correct formula. Choice D is incorrect as it is not the result of the accurate calculation based on the provided information.

3. What advice is most important for a client in the first trimester of pregnancy experiencing nausea?

• A. Practice relaxation techniques when nausea begins.
• B. Increase fluid intake to 3 quarts daily.
• C. Avoid alcohol, caffeine, and smoking.
• D. Eliminate snacks between meals.

Correct answer: C

Rationale: During the first trimester of pregnancy, it is crucial to advise pregnant clients to avoid alcohol, caffeine, and smoking. These substances can worsen nausea and harm fetal development. By eliminating these substances, the client can help alleviate nausea and create a healthier environment for the developing fetus. Choices A, B, and D are not as critical in managing nausea during the first trimester. While relaxation techniques may help, avoiding harmful substances like alcohol, caffeine, and smoking takes precedence. Increasing fluid intake can be beneficial but not as crucial as avoiding harmful substances. Eliminating snacks between meals may not be necessary for all clients and is not directly related to managing nausea in the first trimester.

4. A young girl with a fractured radius has a cast applied. As the cast is drying, it is elevated above the level of her heart. Which assessment finding should the healthcare provider be reported to immediately?

• A. Itching sensation under the cast.
• B. Swelling of fingers with brisk capillary refill.
• C. Numbness and inability to move fingers.
• D. Visible bruising above the cast.

Correct answer: C

Rationale: Numbness and inability to move fingers are concerning findings that suggest potential nerve damage or compartment syndrome due to increased pressure within the cast. This requires immediate notification of the healthcare provider to prevent further complications or permanent damage.

5. An infant with tetralogy of Fallot becomes acutely cyanotic and hyperneic. Which action should the nurse implement first?

• A. Place the infant in a knee-chest position.
• B. Administer morphine sulfate.
• C. Start intravenous fluids.
• D. Provide 100% oxygen by face mask.

Correct answer: A

Rationale: In a tetralogy of Fallot situation, placing the infant in a knee-chest position is the initial priority to help increase systemic vascular resistance, which reduces the right-to-left shunt and improves oxygenation. This position can assist in optimizing oxygen levels before considering other interventions. Administering morphine sulfate (choice B) is not the first-line treatment for tetralogy of Fallot crisis. Starting intravenous fluids (choice C) may be necessary but is not the priority in this situation. Providing 100% oxygen by face mask (choice D) may not fully address the underlying issue of decreased systemic vascular resistance that leads to cyanosis in tetralogy of Fallot.

Similar Questions