Nursing Elites

1. 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.

2. A client with a history of depression and experiencing a situational crisis is being assessed by a nurse. What action should the nurse take first?

• A. Notify the client's support system.
• B. Help the client identify personal strengths.
• C. Confirm the client's perception of the event.
• D. Teach the client relaxation techniques.

Correct answer: A

Rationale: When a client with a history of depression is experiencing a situational crisis, the first action the nurse should take is to notify the client's support system. This is crucial as the client may require immediate assistance and support. While helping the client identify personal strengths and confirming the client's perception of the event are important aspects of the assessment and intervention process, notifying the support system takes priority in ensuring the client's safety and well-being. Teaching relaxation techniques may be beneficial but addressing the client's immediate crisis through support system notification is the most appropriate initial action.

3. A nurse is caring for a client who has heart failure and a prescription for digoxin. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 60/min
• B. Respiratory rate of 16/min
• C. Sodium level of 138 mEq/L
• D. Weight gain of 1.5 kg (3.3 lb) in 24 hours

Correct answer: D

Rationale: The correct answer is D. A weight gain of 1.5 kg (3.3 lb) in 24 hours can indicate fluid retention and worsening heart failure in clients taking digoxin. This rapid weight gain could be due to fluid accumulation, a common sign of heart failure exacerbation. Reporting this finding to the provider is crucial for prompt intervention. Choices A, B, and C are within normal ranges and not directly indicative of worsening heart failure in this context, making them less urgent to report compared to the significant weight gain.

4. A nurse is preparing to administer a blood transfusion to a client. Which of the following actions should the nurse take?

• A. Monitor the client's vital signs every 4 hours.
• B. Start the transfusion with 0.9% sodium chloride.
• C. Administer the transfusion over 6 hours.
• D. Infuse the first 500 mL of blood over 1 hour.

Correct answer: B

Rationale: The correct answer is B: Start the transfusion with 0.9% sodium chloride. 0.9% sodium chloride is the only IV solution that is compatible with blood products and should be used to prime the tubing before a transfusion. Choice A is incorrect because vital signs should be monitored more frequently, typically every 15 minutes at the beginning of the transfusion. Choice C is incorrect as blood transfusions are usually administered over 2-4 hours, not 6 hours. Choice D is incorrect as the first 500 mL of blood should be infused slowly over 1-2 hours to monitor for any adverse reactions.

5. A nurse is providing teaching to a client who is experiencing preterm contractions and dehydration. Which statement should the nurse make?

• A. Dehydration is treated with calcium supplements.
• B. Dehydration can increase the risk of preterm labor.
• C. Dehydration is caused by decreased hemoglobin and hematocrit.
• D. Dehydration causes gastroesophageal reflux.

Correct answer: B

Rationale: The correct statement is B: 'Dehydration can increase the risk of preterm labor.' Dehydration can lead to increased uterine irritability, potentially causing preterm contractions and labor. Choice A is incorrect as dehydration is not treated with calcium supplements but rather with fluids. Choice C is incorrect as dehydration is not caused by decreased hemoglobin and hematocrit levels but rather by a lack of fluids. Choice D is incorrect as dehydration does not directly cause gastroesophageal reflux.

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