Nursing Elites

1. A nurse is assessing a client who is receiving magnesium sulfate for preeclampsia. Which of the following findings should the nurse report to the provider?

• A. Respiratory rate 16/min.
• B. Blood pressure 118/78 mm Hg.
• C. Urinary output of 30 mL/hr.
• D. Absent deep-tendon reflexes.

Correct answer: D

Rationale: The correct answer is D. Absent deep-tendon reflexes indicate magnesium toxicity and should be reported immediately. Magnesium sulfate is used to prevent seizures in clients with preeclampsia, but toxicity can lead to serious complications, including respiratory depression and loss of deep-tendon reflexes. Choices A, B, and C are within normal limits and expected findings in a client receiving magnesium sulfate for preeclampsia, so they do not require immediate reporting.

2. A client with heart failure is receiving a continuous IV infusion of milrinone. Which of the following actions should the nurse take?

• A. Monitor the client's blood pressure continuously
• B. Weigh the client daily
• C. Monitor the infusion site for signs of infiltration
• D. Measure the client's intake and output every 2 hours

Correct answer: D

Rationale: Measuring the client's intake and output every 2 hours is essential when caring for a client receiving a continuous IV infusion of milrinone. Milrinone is a medication that affects fluid balance, and monitoring intake and output helps assess the client's response to the medication. Continuous monitoring of blood pressure may not be necessary unless there is a specific indication. While weighing the client daily is important for overall assessment, measuring intake and output more frequently provides more real-time data for fluid balance evaluation. Monitoring the infusion site is crucial for detecting infiltration but is not directly related to managing fluid balance in this situation.

3. Which laboratory test is essential for monitoring renal function in a patient with chronic kidney disease?

• A. Monitor BUN and creatinine levels
• B. Check blood glucose levels
• C. Monitor hemoglobin and hematocrit levels
• D. Monitor liver enzymes

Correct answer: A

Rationale: The correct answer is to monitor BUN (Blood Urea Nitrogen) and creatinine levels in a patient with chronic kidney disease. These tests provide crucial information about renal function. Checking blood glucose levels (Choice B) is important for monitoring diabetes, not renal function. Monitoring hemoglobin and hematocrit levels (Choice C) helps assess anemia, not specifically renal function. Monitoring liver enzymes (Choice D) is relevant for assessing liver function, not renal function.

4. A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse take?

• A. Perform perineal care before the procedure.
• B. Apply sterile gloves before cleansing the perineal area.
• C. Place the client in a supine position.
• D. Lubricate the catheter with alcohol-based gel.

Correct answer: B

Rationale: Before inserting an indwelling urinary catheter for a female client, the nurse should apply sterile gloves before cleansing the perineal area to prevent infection. Performing perineal care before the procedure is incorrect as it should be done after catheter insertion. Placing the client in a side-lying position is not necessary for this procedure. Lubricating the catheter with petroleum jelly is not recommended as it can damage the catheter; using a water-soluble lubricant is preferred.

5. A nurse is teaching a client who has diabetes mellitus about foot care. Which of the following instructions should the nurse include?

• A. Soak your feet in warm water every day to prevent dryness.
• B. Wear cotton socks to keep your feet dry.
• C. Apply lotion between your toes after bathing.
• D. Cut your toenails in a rounded shape.

Correct answer: B

Rationale: The correct instruction the nurse should include is to 'Wear cotton socks to keep your feet dry.' This is essential in diabetes mellitus as moisture can lead to infections. Choice A is incorrect as soaking feet in warm water can actually cause dryness and skin breakdown, which is harmful in diabetes. Choice C is incorrect as applying lotion between the toes can create excess moisture, increasing the risk of fungal infections. Choice D is incorrect as cutting toenails in a rounded shape can lead to ingrown toenails; clients with diabetes should cut their nails straight across to prevent complications.

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