Nursing Elites

1. A nurse is assessing a client who is 24 hours postpartum. Which of the following findings should the nurse report to the healthcare provider?

• A. Uterine fundus is firm and midline
• B. Client's perineal pad is saturated in 15 minutes
• C. Client reports breast tenderness when breastfeeding
• D. Client's temperature is 100.4°F

Correct answer: B

Rationale: A perineal pad saturated in 15 minutes is a sign of excessive postpartum bleeding, which requires immediate medical attention to prevent postpartum hemorrhage. The other findings are normal postpartum occurrences. A firm and midline uterine fundus indicates proper involution, breast tenderness during breastfeeding is common due to engorgement, and a temperature of 100.4°F is considered within the normal range for the postpartum period.

2. A healthcare professional is assessing a client with deep vein thrombosis (DVT). Which of the following interventions should the healthcare professional include in the plan of care?

• A. Apply ice packs to the affected extremity.
• B. Encourage ambulation every hour.
• C. Elevate the affected leg when in bed.
• D. Massage the affected area to improve circulation.

Correct answer: C

Rationale: Elevating the affected leg is a crucial intervention in the care of a client with deep vein thrombosis (DVT). This position helps reduce swelling and promotes venous return, which can alleviate symptoms associated with DVT. Applying ice packs (Choice A) may worsen the condition by causing vasoconstriction. Encouraging ambulation (Choice B) can dislodge the clot and lead to fatal complications. Massaging the affected area (Choice D) can also dislodge the clot and is contraindicated in DVT.

3. While caring for a client receiving patient-controlled analgesia (PCA), which of the following interventions should the nurse take?

• A. Encourage the client to use the PCA before dressing changes.
• B. Monitor the client's respiratory status.
• C. Provide oxygen therapy to the client as needed.
• D. Ensure the PCA pump is functioning properly.

Correct answer: A

Rationale: Corrected Rationale: The nurse should encourage the client to use the PCA pump before activities like dressing changes, which are likely to cause pain, to ensure effective pain management. Monitoring the client's respiratory status (Choice B) is important but not the priority in this scenario. Providing oxygen therapy (Choice C) is not a routine intervention for all clients on PCA unless specifically indicated. Ensuring the PCA pump is functioning properly (Choice D) is essential, but encouraging the client to use the PCA before painful activities takes precedence to manage pain effectively.

4. A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate. Which action should the nurse take if the client develops toxicity?

• A. Administer calcium gluconate IV
• B. Increase the magnesium sulfate infusion
• C. Administer IV fluids
• D. Administer hydralazine

Correct answer: A

Rationale: In cases of magnesium sulfate toxicity, administering calcium gluconate IV is crucial as it is the antidote for magnesium sulfate. Calcium gluconate helps reverse the effects of magnesium sulfate, especially when signs of toxicity like respiratory depression or loss of reflexes occur. Increasing the magnesium sulfate infusion would worsen toxicity. Administering IV fluids may be beneficial for hydration but does not address magnesium sulfate toxicity. Hydralazine is used to manage hypertension, not magnesium sulfate toxicity.

5. A nurse is preparing to administer furosemide to a client who has a prescription. Which of the following statements by the client indicates a need for further teaching?

• A. I will take my morning pills with food or milk.
• B. I will weigh myself every day.
• C. I will notify the nurse if I have muscle cramps.
• D. I will limit my intake of fish.

Correct answer: D

Rationale: The correct answer is D. There is no need to limit fish intake with furosemide, indicating a misunderstanding of dietary restrictions. Furosemide is a diuretic that helps the body get rid of excess water and salt. Choices A, B, and C are all appropriate actions for a client taking furosemide. Taking morning pills with food or milk can help reduce stomach upset, weighing oneself daily helps monitor fluid retention, and notifying the nurse about muscle cramps can be important due to potential electrolyte imbalances.

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