Nursing Elites

1. A nurse is caring for a client who is experiencing preterm labor and has a new prescription for terbutaline. Which of the following findings is a contraindication for the administration of this medication?

• A. Heart disease
• B. Cervical dilation of 2 cm
• C. Gestational age of 34 weeks
• D. Allergy to penicillin

Correct answer: A

Rationale: The correct answer is A, heart disease. Terbutaline is contraindicated in clients with heart disease because it can lead to tachycardia and other cardiac complications due to its beta-agonist properties. Choice B, cervical dilation of 2 cm, is not a contraindication for terbutaline administration in preterm labor. Choice C, gestational age of 34 weeks, does not contraindicate the use of terbutaline for preterm labor. Choice D, allergy to penicillin, is not related to the contraindications of terbutaline.

2. A nurse is assessing a 1-hour postpartum client and notes a boggy uterus located 2 cm above the umbilicus. Which of the following actions should the nurse take first?

• A. Take vital signs
• B. Assess lochia
• C. Massage the fundus
• D. Give oxytocin IV bolus

Correct answer: C

Rationale: When a nurse assesses a 1-hour postpartum client with a boggy uterus located 2 cm above the umbilicus, it indicates uterine atony. The first action the nurse should take is to massage the fundus. Fundal massage helps stimulate uterine contractions, which will reduce bleeding and prevent postpartum hemorrhage. Taking vital signs, assessing lochia, or administering an oxytocin IV bolus are important interventions but should come after addressing uterine atony through fundal massage.

3. A healthcare provider is assessing a client who has severe dehydration. Which finding indicates effective treatment?

• A. Sunken anterior fontanel
• B. Tenting skin turgor
• C. Flat anterior fontanel
• D. Hyperpnea

Correct answer: C

Rationale: A flat anterior fontanel indicates effective treatment for dehydration in infants. Dehydration often causes sunken fontanels, so when the anterior fontanel becomes flat, it suggests that rehydration has occurred. Sunken anterior fontanel (Choice A) is a sign of dehydration, not effective treatment. Tenting skin turgor (Choice B) is also a sign of dehydration, indicating poor skin turgor. Hyperpnea (Choice D) is increased depth and rate of breathing and is not directly related to the hydration status of the client.

4. A nurse is admitting a client who is at 33 weeks of gestation and has preeclampsia with severe features. Which of the following actions should the nurse take?

• A. Restrict protein intake to less than 40 g/day
• B. Initiate seizure precautions for the client
• C. Initiate an infusion of 0.9% sodium chloride at 150 mL/hr
• D. Encourage the client to ambulate twice per day

Correct answer: B

Rationale: The correct action for the nurse to take is to initiate seizure precautions for the client. Severe preeclampsia increases the risk of seizures (eclampsia), making it crucial to prioritize the safety of the client. Restricting protein intake (Choice A) is not the priority in this situation as seizure prevention takes precedence. While maintaining hydration is essential, starting an infusion of 0.9% sodium chloride (Choice C) is not the initial action needed for seizure prevention. Encouraging the client to ambulate (Choice D) may not be safe or appropriate considering the severity of preeclampsia and the risk of seizures.

5. A client is being educated by a nurse about the use of bupropion. Which of the following should be included?

• A. It can cause weight gain
• B. It may increase seizure risk
• C. It is an SSRI
• D. It has no side effects

Correct answer: B

Rationale: The correct answer is B. Bupropion may lower the seizure threshold, increasing the risk of seizures, especially in clients with a history of seizures. Choice A is incorrect because bupropion is associated with weight loss rather than weight gain. Choice C is incorrect as bupropion is not an SSRI; it is an aminoketone antidepressant. Choice D is incorrect as bupropion, like all medications, can have side effects, and it is essential for clients to be aware of them.

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