Nursing Elites

1. A client is in active labor and is receiving an epidural for pain relief. Which of the following should the nurse monitor as the priority?

• A. Fetal heart rate
• B. Client's blood pressure
• C. Client's respiratory rate
• D. Client's pain level

Correct answer: B

Rationale: The most common side effect of an epidural is hypotension, which can compromise placental perfusion. Monitoring the client's blood pressure is the priority to ensure maternal and fetal well-being. Fetal heart rate is important but monitoring the client's blood pressure takes precedence due to the risk of hypotension. Respiratory rate and pain level monitoring are also important but not the priority in this scenario.

2. A client with rheumatoid arthritis is taking prednisone. Which of the following findings should the nurse identify as an adverse effect of this medication?

• A. Weight loss
• B. Hypoglycemia
• C. Hypertension
• D. Hyperkalemia

Correct answer: C

Rationale: The correct answer is C: Hypertension. Prednisone, a corticosteroid, can lead to hypertension as an adverse effect. Prednisone can cause sodium and water retention, leading to increased blood pressure. Options A, B, and D are incorrect. Weight loss is not typically associated with prednisone use; instead, weight gain is more common. Hypoglycemia is not a common adverse effect of prednisone; in fact, it can elevate blood sugar levels. Hyperkalemia is also not a typical adverse effect of prednisone; instead, it can cause hypokalemia, or low potassium levels.

3. A nurse is providing education to a client in the first trimester of pregnancy. What information should the nurse include regarding the cause of indigestion and heartburn?

• A. Estrogen causes increased appetite
• B. Progesterone causes relaxation of the cardiac sphincter allowing acid to reflux
• C. HCG hormone leads to increased gastric acidity
• D. The uterus compresses the stomach early in pregnancy

Correct answer: B

Rationale: The correct answer is B. Progesterone causes relaxation of the smooth muscles in the body, including the cardiac sphincter. This relaxation allows stomach acid to reflux into the esophagus, leading to heartburn during pregnancy. Choices A, C, and D are incorrect because they do not directly relate to the physiological mechanism that causes heartburn during pregnancy. Estrogen causing increased appetite (Choice A) is not directly linked to heartburn. HCG hormone increasing gastric acidity (Choice C) is not the primary cause of heartburn during pregnancy. The uterus compressing the stomach early in pregnancy (Choice D) may contribute to feelings of fullness or bloating but is not the main cause of heartburn.

4. A nurse is assisting with mass casualty triage following an explosion at a local factory. Which of the following clients should the nurse identify as the priority?

• A. A client who has massive head trauma
• B. A client who has full-thickness burns to the face and trunk
• C. A client with indications of hypovolemic shock
• D. A client with an open fracture of the lower extremity

Correct answer: C

Rationale: In a mass casualty situation, the nurse should prioritize the client with indications of hypovolemic shock. Hypovolemic shock is an immediate life-threatening condition resulting from severe blood loss, which can lead to organ failure and death. Prompt identification and treatment of hypovolemic shock are crucial to prevent further deterioration. While clients with massive head trauma, full-thickness burns, and open fractures require urgent care, hypovolemic shock takes precedence due to its rapid progression to a critical state.

5. A healthcare professional is assessing a client with heart failure. Which of the following signs should the healthcare professional monitor for?

• A. Peripheral edema
• B. Tachycardia
• C. Bradycardia
• D. Hypotension

Correct answer: A

Rationale: In heart failure, the accumulation of fluid can lead to peripheral edema, which is swelling in the extremities. This is a common sign that healthcare professionals should monitor for. While tachycardia (increased heart rate), bradycardia (decreased heart rate), and hypotension (low blood pressure) can also occur in heart failure, they are not the primary signs typically associated with this condition. Therefore, peripheral edema is the most relevant sign to monitor in this case.

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