Nursing Elites

1. A client with preeclampsia and postpartum hemorrhage is being cared for by a nurse. The nurse should recognize that which of the following medications is contraindicated?

• A. Methylergonovine
• B. Misoprostol
• C. Dinoprostone
• D. Oxytocin

Correct answer: A

Rationale: The correct answer is A, Methylergonovine. Methylergonovine is contraindicated in clients with preeclampsia due to the risk of hypertension. Misoprostol (choice B), Dinoprostone (choice C), and Oxytocin (choice D) are appropriate medications for managing postpartum hemorrhage and are not contraindicated in clients with preeclampsia.

2. A nurse is assessing a client who has just received an opioid medication. Which of the following findings should the nurse monitor first?

• A. Constipation.
• B. Drowsiness.
• C. Orthostatic hypotension.
• D. Respiratory depression.

Correct answer: D

Rationale: When a client receives an opioid medication, the nurse should first monitor for respiratory depression as it is a life-threatening adverse effect associated with opioids. This can lead to inadequate ventilation and hypoxia, requiring immediate intervention. Constipation, drowsiness, and orthostatic hypotension are also common side effects of opioids but are not as immediately life-threatening as respiratory depression.

3. A client with heart failure is being assessed by a nurse. Which of the following findings indicates the client is experiencing fluid overload?

• A. Dry, hacking cough
• B. Bounding peripheral pulses
• C. Decreased urinary output
• D. Weight loss of 1 kg in 24 hours

Correct answer: C

Rationale: In clients with heart failure, decreased urinary output is a classic sign of fluid overload. The kidneys try to compensate for the increased volume by reducing urine output, leading to fluid retention. A dry, hacking cough (choice A) is more indicative of heart failure complications like pulmonary edema. Bounding peripheral pulses (choice B) are a sign of increased volume, but not specifically fluid overload. Weight loss of 1 kg in 24 hours (choice D) is not indicative of fluid overload but rather rapid fluid loss.

4. A client receiving morphine via patient-controlled analgesia (PCA) should have naloxone administered if their respiratory rate is below 10/min. What action should the nurse take?

• A. Monitor the client's blood pressure every 4 hours.
• B. Ask the client to rate their pain every 2 hours.
• C. Administer naloxone if the client's respiratory rate is below 10/min.
• D. Evaluate the client's use of the PCA every 4 hours.

Correct answer: C

Rationale: The correct action for the nurse to take is to administer naloxone if the client's respiratory rate falls below 10/min. Naloxone is used to reverse opioid-induced respiratory depression, which is a life-threatening situation. Monitoring the client's blood pressure every 4 hours (Choice A) is not the priority in this scenario as respiratory depression requires immediate attention. Asking the client to rate their pain every 2 hours (Choice B) is important for pain management but addressing respiratory depression takes precedence. Evaluating the client's use of the PCA every 4 hours (Choice D) is a routine nursing intervention but does not directly address the urgent need to reverse respiratory depression in this case.

5. A client is experiencing a seizure. Which of the following interventions should the nurse implement?

• A. Place a tongue depressor in the client's mouth
• B. Loosen tight clothing around the client
• C. Restrain the client's arms and legs
• D. Administer 100% oxygen via non-rebreather mask

Correct answer: B

Rationale: During a seizure, it is essential to loosen tight clothing around the client to prevent injury and promote adequate ventilation. Placing any objects, like a tongue depressor, in the client's mouth can lead to airway obstruction or injury. Restraining the client's arms and legs can exacerbate the situation by increasing muscle rigidity and potentially causing injury. Administering oxygen via a non-rebreather mask is not typically indicated during a seizure unless respiratory distress is present.

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