Nursing Elites

1. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate. The nurse should monitor the client for which of the following findings as an indication of magnesium toxicity?

• A. Decreased deep tendon reflexes
• B. Elevated blood pressure
• C. Increased urinary output
• D. Hyperreflexia

Correct answer: A

Rationale: The correct answer is A: Decreased deep tendon reflexes. Magnesium sulfate toxicity can lead to diminished deep tendon reflexes, respiratory depression, and decreased urine output. Diminished deep tendon reflexes are an early sign of magnesium toxicity and indicate the need to discontinue the infusion. Elevated blood pressure (choice B) is not typically associated with magnesium toxicity. Increased urinary output (choice C) is also not a common finding in magnesium toxicity. Hyperreflexia (choice D) is not consistent with the expected findings of magnesium toxicity, which typically causes decreased reflexes.

2. A nurse is caring for a client who repeatedly refuses meals. The nurse overhears an assistive personnel telling the client, “If you don’t eat, I’ll put restraints on your wrists and feed you.” The nurse should intervene and explain to the AP that this statement constitutes which of the following torts?

• A. Assault
• B. Battery
• C. Malpractice
• D. Negligence

Correct answer: A

Rationale: The correct answer is A: Assault. Assault is the act of threatening a client with harm, such as the threat of using restraints to force-feed the client, even if no physical contact occurs. In this scenario, the statement made by the assistive personnel constitutes assault because it involves the threat of harm. Choice B, Battery, involves actual physical contact without the client's consent, which is not present in the scenario. Choice C, Malpractice, refers to professional negligence or misconduct, not a direct threat to the client. Choice D, Negligence, involves failure to provide reasonable care that results in harm, which is not applicable in this context.

3. A nurse is caring for a client who is at 14 weeks of gestation and has hyperemesis gravidarum. Which of the following medications should the nurse plan to administer?

• A. Digoxin
• B. Calcium gluconate
• C. Vitamin B6
• D. Propranolol

Correct answer: C

Rationale: The correct answer is C: Vitamin B6 (pyridoxine). Vitamin B6 is often used to treat nausea and vomiting in pregnancy, including hyperemesis gravidarum. It is considered safe for use in pregnant clients. Digoxin (Choice A) is a medication used for heart conditions, not for hyperemesis gravidarum. Calcium gluconate (Choice B) is used to treat calcium deficiencies, not nausea and vomiting in pregnancy. Propranolol (Choice D) is a beta-blocker used for conditions like hypertension and anxiety, not for hyperemesis gravidarum.

4. A nurse is caring for a client who has end-stage osteoporosis and is reporting severe pain. The client’s respiratory rate is 14 per minute. Which of the following medications should the nurse prioritize administering?

• A. Promethazine
• B. Hydromorphone
• C. Ketorolac
• D. Amitriptyline

Correct answer: B

Rationale: Hydromorphone, an opioid, is the most appropriate option for managing severe pain in this context. Opioids provide fast-acting relief for acute pain associated with advanced osteoporosis. Promethazine (Choice A) is an antihistamine and not indicated for pain relief. Ketorolac (Choice C) is a nonsteroidal anti-inflammatory drug (NSAID) that may increase the risk of bleeding and is not recommended for severe pain management. Amitriptyline (Choice D) is a tricyclic antidepressant that is not the first-line treatment for severe acute pain.

5. A client is receiving vancomycin. Which of the following should the nurse monitor?

• A. Blood glucose levels
• B. Serum creatinine
• C. INR levels
• D. Liver function tests

Correct answer: B

Rationale: The correct answer is B: Serum creatinine. Vancomycin is known to be nephrotoxic, meaning it can cause kidney damage. Monitoring serum creatinine levels is essential to assess kidney function and detect any signs of nephrotoxicity. Blood glucose levels (choice A) are not directly affected by vancomycin. INR levels (choice C) are typically monitored for clients on anticoagulants, not vancomycin. Liver function tests (choice D) are not primarily affected by vancomycin use; kidney function is of greater concern.

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