Nursing Elites

1. A postpartum client's fundus is firm, 3 cm above the umbilicus, and displaced to the right. Which of the following interventions should the nurse take?

• A. Massage the fundus
• B. Administer oxytocin
• C. Assist the client to void then reassess the fundus
• D. Notify the healthcare provider

Correct answer: C

Rationale: The correct intervention for a postpartum client with a firm, displaced fundus is to assist the client to void then reassess the fundus. Displacement of the uterus to the right is often a sign of bladder distention, which can prevent the uterus from contracting properly and increase the risk of postpartum hemorrhage. By helping the client to void, the nurse can alleviate the bladder distention, allowing the uterus to contract effectively. Massaging the fundus (Choice A) may not address the underlying issue of bladder distention. Administering oxytocin (Choice B) is not indicated without assessing and addressing the cause of the displacement. Notifying the healthcare provider (Choice D) is premature before implementing initial nursing interventions to address the potential cause of the displaced fundus.

2. A client is being treated for eclampsia. What is a priority nursing intervention?

• A. Assess for hyperreflexia
• B. Administer oxygen
• C. Monitor blood pressure every 15 minutes
• D. Prepare for delivery

Correct answer: A

Rationale: The correct answer is to 'Assess for hyperreflexia.' Eclampsia is a severe complication of pregnancy that involves seizures. Hyperreflexia, an overactive or overresponsive reflex, is often an early sign of impending eclampsia. By assessing for hyperreflexia, nurses can identify this warning sign and take preventive measures to manage the condition before seizures occur. Administering oxygen (Choice B) may be necessary but is not the priority in this situation. Monitoring blood pressure (Choice C) is important but assessing for hyperreflexia takes precedence as it can lead to immediate life-threatening complications. While preparing for delivery (Choice D) may ultimately be necessary, the immediate priority is to assess for hyperreflexia to prevent seizures.

3. A nurse is caring for a group of patients. Which of the following clients should the nurse refer to a social worker?

• A. A patient who requests to secure an emergency notification system in the home.
• B. A client who requires placement in an assisted living facility.
• C. A patient who requests to get school assignments while hospitalized on a pediatric unit.
• D. A patient who is experiencing food insecurity.

Correct answer: B

Rationale: The correct answer is B because social workers are involved in arranging care services like placement in assisted living facilities. This client's need for placement in an assisted living facility requires the expertise and assistance of a social worker. Choices A, C, and D do not necessarily require the intervention of a social worker. Choice A can be addressed by a nurse or healthcare provider, choice C can be managed by hospital staff or educators, and choice D may involve a nutritionist or community outreach programs.

4. A client is receiving magnesium sulfate for preeclampsia. Which finding indicates magnesium toxicity?

• A. Respiratory rate of 12/min
• B. Diminished deep tendon reflexes
• C. Urine output 40 mL/hr
• D. Systolic blood pressure of 140 mm Hg

Correct answer: B

Rationale: Diminished deep tendon reflexes are a sign of magnesium toxicity. Magnesium sulfate can depress the central nervous system, leading to decreased reflexes. Respiratory rate of 12/min, urine output 40 mL/hr, and systolic blood pressure of 140 mm Hg are not specific findings of magnesium toxicity. Respiratory depression, oliguria, and hypotension are more concerning signs that require immediate attention.

5. A client just received their first dose of lisinopril. Which of the following is an appropriate nursing intervention?

• A. Place the client on cardiac monitoring
• B. Monitor the client’s oxygen saturation
• C. Provide standby assistance when the client gets out of bed
• D. Encourage foods high in potassium

Correct answer: C

Rationale: The correct answer is to provide standby assistance when the client gets out of bed. Lisinopril can cause hypotension, especially after the first dose, which can lead to dizziness and falls. Standby assistance helps prevent potential injury. Placing the client on cardiac monitoring (choice A) or monitoring oxygen saturation (choice B) are not typically necessary after the first dose of lisinopril unless specific symptoms are present. Encouraging foods high in potassium (choice D) is not directly related to the immediate concern of postural hypotension associated with lisinopril.

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