Nursing Elites

1. A nurse in a mental health facility receives a change-of-shift report on four clients. Which of the following clients should the nurse assess first?

• A. Client placed in restraints for aggressive behavior
• B. A new client with a history of a 4.5 kg weight loss in the past two months
• C. Client who received a PRN dose of haloperidol 2 hours ago for increased anxiety
• D. Client who will be receiving his first ECT treatment today

Correct answer: A

Rationale: A client in restraints due to aggressive behavior needs immediate assessment to ensure safety and well-being. The nurse should assess this client first to address any potential risks, such as circulation issues, skin integrity problems, and ongoing agitation. Choices B, C, and D do not present immediate safety concerns that require urgent assessment compared to a client restrained for aggressive behavior.

2. A client is being treated with thiazide diuretics. What should the nurse monitor regularly?

• A. Hyperkalemia
• B. Hypokalemia
• C. Hyponatremia
• D. Hypoglycemia

Correct answer: B

Rationale: Thiazide diuretics are known to cause hypokalemia by increasing potassium excretion in the urine. Therefore, the nurse should monitor the client for low potassium levels. Hyperkalemia (Choice A) is not typically associated with thiazide diuretics. Hyponatremia (Choice C) is more commonly linked with thiazide diuretics due to increased sodium excretion. Hypoglycemia (Choice D) is not a usual concern when a client is receiving thiazide diuretics.

3. A nurse is caring for an infant who has a prescription for continuous pulse oximetry. Which of the following is an appropriate action for the nurse to take?

• A. Place the infant under a radiant warmer
• B. Move the probe site every 3 hours
• C. Heat the skin one minute prior to placing the probe
• D. Place the sensor on the index finger

Correct answer: B

Rationale: The correct answer is to move the probe site every 3 hours. This action helps prevent skin breakdown and ensures more accurate monitoring of oxygen saturation. Placing the infant under a radiant warmer (choice A) is unnecessary and not related to pulse oximetry. Heating the skin before placing the probe (choice C) can lead to burns and is not recommended. Placing the sensor on the index finger (choice D) is not appropriate for continuous monitoring in infants.

4. A nurse is caring for a client who is at 38 weeks of gestation and is experiencing continuous abdominal pain and vaginal bleeding. The client has a history of cocaine use. The nurse should identify that the client is likely experiencing which of the following complications?

• A. Abruptio placentae
• B. Hydatidiform mole
• C. Preterm labor
• D. Placenta previa

Correct answer: A

Rationale: Continuous abdominal pain and vaginal bleeding in a client with a history of cocaine use suggest abruptio placentae, where the placenta detaches from the uterus prematurely, posing serious risks to both mother and fetus. Hydatidiform mole is characterized by abnormal trophoblastic tissue growth, not continuous pain and bleeding. Preterm labor is premature contractions leading to birth before 37 weeks gestation. Placenta previa involves the placenta partially or completely covering the cervix, presenting with painless vaginal bleeding.

5. A nurse is caring for a client at 32 weeks gestation with a history of cardiac disease. Which position should the nurse recommend to promote optimal cardiac output?

• A. The chest
• B. Standing
• C. Supine
• D. Left lateral

Correct answer: D

Rationale: The left lateral position is the correct choice to promote optimal cardiac output in a pregnant client at 32 weeks gestation with cardiac disease. This position improves venous return and decreases pressure on the vena cava, helping optimize cardiac output. Standing (choice B) would not be recommended as it may decrease venous return. The supine position (choice C) should be avoided in pregnant clients with cardiac disease as it can compress the vena cava, reducing cardiac output and potentially causing hypotension. The chest (choice A) is not a valid position recommendation for optimizing cardiac output in this scenario.

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