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 has a new prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include?

• A. You should lie down before taking this medication.
• B. You should take this medication on an empty stomach.
• C. You should never take a double dose if you miss one.
• D. You should store this medication in its original container at room temperature.

Correct answer: A

Rationale: The correct instruction for a client prescribed nitroglycerin sublingual tablets is to lie down before taking the medication. Nitroglycerin can cause a sudden drop in blood pressure leading to dizziness or fainting, so taking the medication while lying down helps prevent falls. Choice B is incorrect because nitroglycerin is usually taken on an empty stomach to enhance its absorption. Choice C is incorrect as taking a double dose of nitroglycerin can lead to low blood pressure and other adverse effects. Choice D is incorrect as nitroglycerin sublingual tablets should be stored in their original container at room temperature away from light and moisture, not in the refrigerator.

3. A healthcare provider is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which finding should the healthcare provider identify as a contraindication to the administration of clozapine?

• A. Heart rate 58/min.
• B. Fasting blood glucose 100 mg/dL.
• C. Hgb 14 g/dL.
• D. WBC count 2,900/mm3.

Correct answer: D

Rationale: The correct answer is D: a low WBC count. Clozapine can suppress bone marrow function, leading to a decreased white blood cell count. This condition, known as agranulocytosis, increases the risk of severe infections. Monitoring WBC counts is essential during clozapine therapy. Choices A, B, and C are within normal ranges and are not contraindications for administering clozapine.

4. A nurse is caring for a client following the application of a cast. Which of the following actions should the nurse take first?

• A. Place an ice pack over the cast
• B. Palpate the pulse distal to the cast
• C. Teach the client to keep the cast clean and dry
• D. Position the casted extremity on a pillow

Correct answer: B

Rationale: Palpating the pulse distal to the cast is the priority as it assesses for circulation. Ensuring adequate blood flow is essential to prevent complications such as compartment syndrome. Placing an ice pack over the cast could cause constriction of blood vessels, further compromising circulation. Teaching the client about cast care and positioning the casted extremity on a pillow are important but do not take precedence over assessing circulation.

5. A nurse is teaching a client who is at 10 weeks gestation about the amniocentesis procedure. Which of the following statements should the nurse make?

• A. This test will confirm whether your baby has a genetic disorder.
• B. Amniocentesis is used to assess your baby's lung maturity.
• C. You should not feel any pain during this procedure.
• D. This test will assess the amount of amniotic fluid around your baby.

Correct answer: A

Rationale: The correct answer is A because amniocentesis is a procedure that confirms genetic disorders by analyzing the amniotic fluid surrounding the baby. Choice B is incorrect because amniocentesis is not used to assess lung maturity. Choice C is incorrect because some discomfort or pain may be felt during the procedure. Choice D is incorrect because amniocentesis does not primarily assess the amount of amniotic fluid around the baby.

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