Nursing Elites

1. A nurse is reviewing the medical record of a client who is at 30 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?

• A. Blood pressure 140/90 mm Hg
• B. 1+ pitting edema in the lower extremities
• C. Weight gain of 2.3 kg (5 lb) in 1 week
• D. Mild headache

Correct answer: C

Rationale: A weight gain of 2.3 kg (5 lb) in 1 week can indicate worsening preeclampsia due to fluid retention, which can lead to serious complications. This finding should be reported promptly to the provider for further assessment and intervention. Blood pressure of 140/90 mm Hg is high but may not be an immediate concern for a client with preeclampsia at 30 weeks. 1+ pitting edema in the lower extremities is common in pregnancy, especially in the third trimester, and may not be a significant finding in isolation. A mild headache can be a common symptom in pregnancy and may not be indicative of worsening preeclampsia unless accompanied by other concerning signs.

2. A nurse is teaching a newly licensed nurse about using a portable oxygen system. What instruction should the nurse include?

• A. The oxygen should be kept in a storage room when not in use.
• B. Turn off the oxygen when not in use.
• C. Check the oxygen level regularly using a pulse oximeter.
• D. Never leave the oxygen running when transporting a client.

Correct answer: C

Rationale: The correct answer is to check the oxygen level regularly using a pulse oximeter. This instruction is crucial as it ensures safe and adequate oxygenation for the client. Option A is incorrect as oxygen should not be stored in a storage room but in a well-ventilated area. Option B is not ideal as oxygen should be left on unless otherwise specified by a healthcare provider. Option D is also important but not directly related to the primary instruction of monitoring oxygen levels.

3. A nurse is observing bonding between the client and her newborn. Which of the following actions by the client requires the nurse to intervene?

• A. Holding the newborn in an en face position
• B. Asking the father to change the newborn's diaper
• C. Requesting the nurse to take the newborn to the nursery so she can rest
• D. Viewing the newborn's actions as uncooperative

Correct answer: D

Rationale: The correct answer is D because viewing the newborn's actions as uncooperative may indicate the client is struggling to bond, requiring intervention. Choices A, B, and C do not raise concerns about the bonding process between the client and the newborn. Holding the newborn in an en face position is a positive interaction. Asking the father to change the newborn's diaper involves family participation in care. Requesting the nurse to take the newborn to the nursery so she can rest is a valid request for maternal self-care.

4. A nurse is caring for a client who has depression and reports taking St. John's wort along with citalopram. The nurse should monitor the client for which of the following conditions as a result of an interaction between these substances?

• A. Serotonin syndrome
• B. Tardive dyskinesia
• C. Pseudo-parkinsonism
• D. Acute dystonia

Correct answer: A

Rationale: The correct answer is A: Serotonin syndrome. When a client takes St. John's wort, a herbal supplement, along with citalopram, a selective serotonin reuptake inhibitor (SSRI), there is a risk of developing serotonin syndrome. Serotonin syndrome is a potentially life-threatening condition characterized by symptoms such as confusion, agitation, fever, sweating, shivering, tremors, muscle rigidity, and in severe cases, seizures and coma. It is crucial for the nurse to monitor the client for these symptoms. Choices B, C, and D are incorrect because tardive dyskinesia is associated with long-term use of antipsychotic medications, pseudo-parkinsonism is a side effect of antipsychotic medications like haloperidol, and acute dystonia is a side effect of antipsychotic medications characterized by sustained muscle contractions.

5. A nurse is caring for a client who is 36 weeks gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?

• A. Proteinuria of 1+.
• B. Blood pressure 120/80 mm Hg.
• C. Respiratory rate of 18/min.
• D. Nonpitting ankle edema.

Correct answer: D

Rationale: Nonpitting ankle edema is a concerning sign of worsening preeclampsia due to fluid retention and should be reported immediately. Proteinuria of 1+ is a common finding in preeclampsia. A blood pressure of 120/80 mm Hg is within normal limits. A respiratory rate of 18/min is also within normal range. Therefore, choices A, B, and C are not as urgent as nonpitting ankle edema in this scenario.

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