Nursing Elites

1. A nurse is caring for a client prescribed hydroxychloroquine. Which of the following should the nurse monitor?

• A. Liver function tests
• B. Eye exams
• C. Blood glucose levels
• D. Complete blood count

Correct answer: B

Rationale: The correct answer is B: Eye exams. Hydroxychloroquine can cause retinal damage, making it essential for the nurse to monitor the client's eyes regularly for any changes. Monitoring liver function tests (choice A), blood glucose levels (choice C), or complete blood count (choice D) are not directly associated with the potential side effects of hydroxychloroquine.

2. A client who gave birth 12 hours ago is experiencing excessive vaginal bleeding. Which of the following findings indicates the client is experiencing decreased cardiac output?

• A. Bradycardia
• B. Flushed face
• C. Hypotension
• D. Polyuria

Correct answer: C

Rationale: Hypotension is a key indicator of decreased cardiac output, especially in the context of postpartum hemorrhage, which can lead to significant fluid volume loss and compromise perfusion. In this scenario, the excessive vaginal bleeding could lead to hypovolemia, resulting in decreased cardiac output and subsequent hypotension. Bradycardia (choice A) is not typically associated with decreased cardiac output in this scenario, as the body often compensates for decreased cardiac output by increasing heart rate. A flushed face (choice B) may indicate vasodilation but is not a direct indicator of decreased cardiac output. Polyuria (choice D) is excessive urination and is not a specific indicator of decreased cardiac output in this context.

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 teaching a client who is taking prednisone about the adverse effects of this medication. Which of the following should the nurse emphasize?

• A. Weight gain
• B. Insomnia
• C. Hyperglycemia
• D. Hypertension

Correct answer: C

Rationale: The correct adverse effect of prednisone that the nurse should emphasize is hyperglycemia. Prednisone is known to increase blood sugar levels, leading to hyperglycemia. While weight gain and other metabolic changes are possible side effects, hyperglycemia is a more critical concern due to the risk of uncontrolled blood sugar levels and its impact on overall health. Insomnia and hypertension are not typically associated with prednisone use, making them less relevant to emphasize during client education.

5. A client who is having suicidal thoughts tells the nurse, “It just doesn’t seem worth it anymore. Why not end my misery?” Which of the following responses by the nurse is appropriate?

• A. Why do you think your life is not worth it anymore?
• B. Do you have a plan to end your life?
• C. I need to know what you mean by misery
• D. You can trust me and tell me what you’re thinking

Correct answer: B

Rationale: The appropriate response by the nurse is to ask about the client's plan to end their life. This question helps to assess the severity of the client's suicidal ideation and the immediacy of the risk, allowing the nurse to determine the appropriate level of intervention. Choices A, C, and D do not directly address the immediate risk assessment needed in this situation.

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