Nursing Elites

1. A client with myasthenia gravis (MG) is receiving immunosuppressive therapy. Review of recent laboratory test results shows that the client’s serum magnesium level has decreased below the normal range. In addition to contacting the healthcare provider, what nursing action is most important?

• A. Check the visual difficulties
• B. Note the most recent hemoglobin level
• C. Assess for hand and joint pain
• D. Observe rhythm on telemetry monitor

Correct answer: D

Rationale: The correct answer is to observe the rhythm on the telemetry monitor. Decreased magnesium levels can lead to cardiac issues, such as arrhythmias. Monitoring the heart rhythm is crucial in this situation. Checking visual difficulties (choice A) is not directly related to the potential cardiac effects of low magnesium levels. Noting the hemoglobin level (choice B) and assessing for hand and joint pain (choice C) are not the priority when dealing with low magnesium levels and possible cardiac complications.

2. What action should the nurse take after a client produces the first of a series of sputum samples for cytology?

• A. Ensure the client remains NPO until all samples are collected
• B. Transport the sputum container to the laboratory in a biohazard bag
• C. Discard the initial sample and document the time it was obtained
• D. Document the time the client last ate or drank on the laboratory slip

Correct answer: B

Rationale: The correct action for the nurse to take after a client produces the first of a series of sputum samples for cytology is to transport the sputum container to the laboratory in a biohazard bag. This is important to ensure proper handling and prevent contamination of the sample. Choice A is incorrect because there is no need to keep the client NPO until all samples are collected. Choice C is incorrect as the initial sample should not be discarded but rather transported to the laboratory. Choice D is also incorrect as documenting the time the client last ate or drank is not directly relevant to the immediate action needed for the sputum sample.

3. The nurse is planning care for a client with end-stage lung cancer. The client expresses concern about ongoing pain management. Which nursing action is most appropriate to include in the plan of care?

• A. Consult the healthcare provider for recommendations on pain management
• B. Schedule the client for physical therapy to manage pain
• C. Recommend the client attend a support group for cancer patients
• D. Suggest alternative therapies like acupuncture or massage

Correct answer: A

Rationale: Consulting the healthcare provider for recommendations on pain management is the most appropriate action. The healthcare provider can assess the client's pain, prescribe appropriate medications, and adjust the pain management plan as needed. In end-stage cancer, managing pain often requires pharmacological interventions that the healthcare provider can best provide. Physical therapy (choice B) may not be the primary intervention for pain management in end-stage cancer. While attending a support group (choice C) can provide emotional support, it does not directly address the client's pain management concerns. Suggesting alternative therapies (choice D) is not the initial step; consulting the healthcare provider should come first to ensure a comprehensive and tailored pain management plan.

4. The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client’s plan of care?

• A. Record urine output every hour
• B. Monitor blood pressure frequently
• C. Evaluate neurological status
• D. Maintain seizure precautions

Correct answer: B

Rationale: Pheochromocytoma is associated with severe hypertension due to excessive catecholamine release. Monitoring blood pressure frequently is the priority intervention to assess for hypertensive crises and prevent complications like stroke, heart attack, or organ damage. While recording urine output every hour, evaluating neurological status, and maintaining seizure precautions are important aspects of care, they are not the highest priority in a client with pheochromocytoma.

5. Two hours after delivering a 9-pound infant, a client saturates a perineal pad every 15 minutes. Although an IV containing Pitocin is infusing, her uterus remains boggy, even with massage. The healthcare provider prescribes methylergometrine maleate (Methergine) 0.2 mg IM STAT. Which complication should the nurse be alert to this client developing?

• A. Decreased respiratory rate
• B. Increased temperature
• C. Tachycardia
• D. Hypertension

Correct answer: D

Rationale: The correct answer is D: Hypertension. Methylergometrine maleate (Methergine) is a medication used to prevent or control postpartum hemorrhage by causing uterine contractions. One of the potential side effects is hypertension. Therefore, the nurse should closely monitor the client's blood pressure after administering Methergine. Choices A, B, and C are incorrect because Methergine is not known to cause decreased respiratory rate, increased temperature, or tachycardia.

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