Nursing Elites

1. A nurse is caring for a client in preterm labor who is receiving magnesium sulfate. Which of the following is an indication of magnesium toxicity?

• A. Blood glucose of 160 mg/dL
• B. Urine output of 20 mL/hour
• C. Systolic BP of 140 mm Hg
• D. Respiratory rate of 20/min

Correct answer: B

Rationale: The correct answer is B: Urine output of 20 mL/hour. Urine output below 30 mL/hour is a sign of magnesium toxicity due to the risk of accumulation in the body. Choices A, C, and D are not indicative of magnesium toxicity. Elevated blood glucose, systolic blood pressure, and normal respiratory rate are not specific signs of magnesium toxicity.

2. A healthcare professional is preparing to administer ceftriaxone. Which of the following actions should the healthcare professional take?

• A. Reconstitute the medication with normal saline
• B. Reconstitute the medication with sterile water
• C. Administer the medication over 30 minutes
• D. Monitor for signs of toxicity

Correct answer: B

Rationale: Correct Answer: B. Ceftriaxone should be reconstituted with sterile water, not saline. Reconstituting it with normal saline can result in a chemical interaction and precipitation of the drug. Administering the medication over 30 minutes (choice C) is not necessary as ceftriaxone is usually given as an intravenous bolus or drip over a shorter period. Monitoring for signs of toxicity (choice D) is important but not the immediate action required for preparing the medication. The priority is to ensure proper reconstitution with the appropriate solvent, which is sterile water.

3. A nurse is caring for a client who is receiving oxytocin IV for augmentation of labor. The client’s contractions are occurring every 45 seconds with a duration of 90 seconds, and the fetal heart rate is 170-180/minute. Which of the following actions should the nurse take?

• A. Discontinue the oxytocin infusion
• B. Increase the oxytocin infusion
• C. Decrease the oxytocin infusion
• D. Maintain the oxytocin infusion

Correct answer: A

Rationale: In this scenario, the contractions are too frequent (tachysystole), and the fetal heart rate is elevated. Tachysystole can lead to decreased oxygen perfusion to the fetus, causing fetal distress. Therefore, the correct action for the nurse to take is to discontinue the oxytocin infusion to prevent harm to both the mother and fetus. Increasing or maintaining the oxytocin infusion would exacerbate the current situation, potentially leading to further complications. Decreasing the oxytocin infusion may not be sufficient to address the tachysystole and elevated fetal heart rate, making it an inappropriate choice.

4. A nurse is caring for a group of patients. Which of the following clients should the nurse refer to a social worker?

• A. A patient who requests to secure an emergency notification system in the home.
• B. A client who requires placement in an assisted living facility.
• C. A patient who requests to get school assignments while hospitalized on a pediatric unit.
• D. A patient who is experiencing food insecurity.

Correct answer: B

Rationale: The correct answer is B because social workers are involved in arranging care services like placement in assisted living facilities. This client's need for placement in an assisted living facility requires the expertise and assistance of a social worker. Choices A, C, and D do not necessarily require the intervention of a social worker. Choice A can be addressed by a nurse or healthcare provider, choice C can be managed by hospital staff or educators, and choice D may involve a nutritionist or community outreach programs.

5. A client who was incarcerated for theft is addressing the group in a County Jail health clinic. Which of the following is an example of reaction formation?

• A. I steal things because it’s the only way I can keep my mind off my bad marriage
• B. I can’t believe I was accused of something I didn’t do
• C. I don’t want to talk about my feelings right now; we will talk more next time
• D. I think that people should earn money honestly, even though I stole

Correct answer: D

Rationale: The correct answer is D because reaction formation occurs when a person expresses the opposite of what they feel. In this case, the client is advocating for honesty, despite their own history of theft. Choice A discusses stealing to distract from a bad marriage, which does not involve expressing the opposite of one's feelings. Choice B focuses on denial, not reaction formation. Choice C involves delaying emotional discussion, which is not related to expressing the opposite of one's true feelings.

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