Nursing Elites

1. A nurse is caring for a client in preterm labor who is receiving magnesium sulfate by continuous IV infusion. Which of the following client findings indicates medication toxicity?

• A. Blood glucose of 150 mg/dL
• B. Urine output of 20 mL per hour
• C. Systolic blood pressure of 140 mm Hg
• D. BUN 20 mg/dL

Correct answer: B

Rationale: A urine output of 20 mL per hour is low and indicates renal insufficiency, a sign of magnesium sulfate toxicity. The medication is excreted by the kidneys, so toxicity can occur if renal function declines. Blood glucose of 150 mg/dL is within normal range and not indicative of magnesium sulfate toxicity. A systolic blood pressure of 140 mm Hg is elevated but not specifically related to magnesium sulfate toxicity. A BUN level of 20 mg/dL is also within normal limits and not a sign of medication toxicity.

2. A nurse is teaching a client about dietary modifications for a low-sodium diet. Which of the following should the nurse include?

• A. Limit intake of processed foods
• B. Increase intake of fresh fruits and vegetables
• C. Use of accessory muscles
• D. Monitor for allergic reactions

Correct answer: A

Rationale: The correct answer is to limit intake of processed foods. Processed foods are often high in sodium, which goes against the goal of a low-sodium diet. Fresh fruits and vegetables are recommended for a low-sodium diet due to their natural low sodium content. The use of accessory muscles and monitoring for allergic reactions are not related to dietary modifications for a low-sodium diet.

3. A client with diabetes is receiving education on foot care. Which of the following should be included in the teaching?

• A. Inspect feet daily for cuts and sores
• B. Soak feet in warm water daily
• C. Wear closed-toe shoes at all times
• D. Trim toenails straight across

Correct answer: A

Rationale: The correct answer is A: Inspect feet daily for cuts and sores. Clients with diabetes are at an increased risk of foot complications, so it is essential to check for any cuts, sores, or injuries daily to prevent infections and complications. Soaking feet in warm water daily (choice B) is not recommended as it can lead to skin breakdown. Wearing closed-toe shoes at all times (choice C) is not advisable as it can cause excessive pressure and friction. Trimming toenails straight across (choice D) is the correct method to prevent ingrown toenails, not trimming them in a rounded shape.

4. A client has a new prescription for metformin. Which of the following should the nurse educate the client about?

• A. It can cause weight gain
• B. It should be taken with meals
• C. It is an injectable medication
• D. It can cause hypoglycemia

Correct answer: B

Rationale: The correct answer is B: 'It should be taken with meals.' Metformin should be taken with meals to minimize gastrointestinal side effects and improve absorption. Choice A is incorrect because metformin is actually associated with weight loss or weight neutrality. Choice C is incorrect as metformin is typically taken orally and not via injection. Choice D is also incorrect because metformin is not known to cause hypoglycemia as a primary side effect.

5. A nurse is assessing a client who was brought to the psychiatric emergency services by law enforcement. The client has disorganized, incoherent speech with loose associations and religious content. The nurse should recognize these signs and symptoms as consistent with which of the following?

• A. Alzheimer's disease
• B. Schizophrenia
• C. Substance intoxication
• D. Depression

Correct answer: B

Rationale: The correct answer is B: Schizophrenia. Disorganized speech, loose associations, and religious delusions are characteristic symptoms of schizophrenia. In this scenario, the client's presentation aligns with positive symptoms of schizophrenia, indicating a severe mental disorder requiring immediate attention. Choice A, Alzheimer's disease, primarily involves cognitive decline and memory impairment, not disorganized speech or religious content. Choice C, Substance intoxication, may present with altered mental status but typically lacks the persistent pattern of symptoms seen in schizophrenia. Choice D, Depression, is associated with a different set of symptoms such as low mood, anhedonia, and changes in appetite or sleep, rather than disorganized speech and loose associations.

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