Nursing Elites

1. A client with heart failure is receiving furosemide. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 80/min.
• B. Weight loss of 1.1 kg (2.5 lb) in 24 hours.
• C. Potassium level of 3.8 mEq/L.
• D. Urine output of 60 mL/hr.

Correct answer: B

Rationale: A weight loss of 1.1 kg (2.5 lb) in 24 hours may indicate dehydration or fluid imbalance, which should be reported. This rapid weight loss could be a sign of excessive diuresis, potentially leading to hypovolemia or electrolyte imbalances. Monitoring weight changes is crucial in clients with heart failure receiving diuretics. The other findings are within normal ranges and expected in a client receiving furosemide for heart failure. A heart rate of 80/min, a potassium level of 3.8 mEq/L, and a urine output of 60 mL/hr are generally acceptable in this scenario.

2. A nurse is caring for a client who is at 28 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?

• A. Blood pressure 120/80 mm Hg
• B. Weight gain of 0.9 kg (2 lb) in 1 week
• C. Urine output of 30 mL/hr
• D. Respiratory rate 16/min

Correct answer: B

Rationale: A weight gain of 0.9 kg (2 lb) in 1 week is an indication of fluid retention, which is concerning in a client with preeclampsia. This can be a sign of worsening condition requiring immediate medical attention. High blood pressure (option A) is expected in preeclampsia, a urine output of 30 mL/hr (option C) is decreased but not as urgent as the weight gain in this scenario, and a respiratory rate of 16/min (option D) is within normal limits.

3. A nurse is assessing a client in active labor. The FHR baseline has been 100/min for 15 minutes. What condition should the nurse suspect?

• A. Maternal fever.
• B. Fetal anemia.
• C. Maternal hypoglycemia.
• D. Chorioamnionitis.

Correct answer: C

Rationale: In this scenario, with a fetal heart rate (FHR) baseline of 100/min for 15 minutes, the nurse should suspect maternal hypoglycemia. Maternal hypoglycemia can result in fetal bradycardia, which is defined as an FHR less than 110 beats per minute. Maternal hypoglycemia requires prompt intervention to prevent adverse outcomes for both the mother and the fetus. Maternal fever (Choice A) typically presents with tachycardia rather than bradycardia in the fetus. Fetal anemia (Choice B) is more likely to present with other signs such as pallor or tachycardia rather than bradycardia. Chorioamnionitis (Choice D) is characterized by maternal fever, uterine tenderness, and foul-smelling amniotic fluid, but it is not directly linked to the FHR baseline being 100/min.

4. What is the priority nursing assessment for a patient who has just returned from surgery?

• A. Monitor respiratory rate
• B. Monitor blood pressure
• C. Check the surgical site
• D. Monitor heart rate

Correct answer: A

Rationale: The correct answer is to monitor the patient's respiratory rate. This assessment is essential as it ensures that the patient is breathing adequately post-surgery. Maintaining a patent airway and adequate oxygenation are the top priorities in the immediate postoperative period. Monitoring blood pressure, checking the surgical site, or monitoring heart rate are important assessments but are not the priority immediately upon the patient's return from surgery.

5. How should a healthcare provider manage a patient who is experiencing acute pain?

• A. Administer analgesics as prescribed
• B. Reposition the patient to alleviate pain
• C. Offer non-pharmacological interventions
• D. Administer IV fluids

Correct answer: A

Rationale: Corrected Rationale: Administering prescribed analgesics is the most effective way to manage acute pain. Analgesics help in reducing or eliminating pain quickly and efficiently. Repositioning the patient may be helpful in certain cases to relieve discomfort, but it is not the primary intervention for managing acute pain. Non-pharmacological interventions can be beneficial as adjuncts to pain management, but in cases of acute pain, administering analgesics is the priority. Administering IV fluids may be necessary for certain conditions but is not the primary intervention for managing acute pain.

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