Nursing Elites

1. In a client in her third trimester of pregnancy, an S3 heart sound is auscultated. What intervention should the nurse take?

• A. Notify the healthcare provider
• B. Limit the client’s fluids
• C. Prepare the client for an echocardiogram
• D. Document in the client’s record

Correct answer: D

Rationale: An S3 heart sound can be a normal finding in pregnancy due to increased blood volume and flow. In this scenario, there is no immediate need for further interventions. Documenting this finding in the client's record is essential for tracking the client's health status and ensuring proper follow-up if needed. Notifying the healthcare provider, limiting fluids, or preparing for an echocardiogram is unnecessary as it is likely a physiological finding in pregnancy. These interventions should only be considered if other symptoms suggestive of a cardiac issue are present.

2. A client with intestinal obstructions has a nasogastric tube to low intermittent suction and is receiving an IV of lactated Ringer’s at 100 ml/H. Which finding is most important for the nurse to report to the healthcare provider?

• A. Gastric output of 900 mL in the last 24 hours
• B. Serum potassium level of 3.1 mEq/L or mmol/L (SI)
• C. Increased blood urea nitrogen (BUN)
• D. 24-hour intake at the current infusion rate

Correct answer: B

Rationale: The most crucial finding to report to the healthcare provider in this scenario is a serum potassium level of 3.1 mEq/L. Hypokalemia can lead to serious complications, including cardiac issues. Gastric output, increased BUN, and monitoring the 24-hour intake are essential but do not pose an immediate risk as hypokalemia does in this situation.

3. When caring for a laboring client whose contractions are occurring every 2 to 3 minutes, the nurse should document that the pump is infusing how many ml/hour? (Enter numeric value only. If rounding is required, round to the nearest whole number. Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client’s medical record.)

• A. 42
• B. 38
• C. 48
• D. 50

Correct answer: A

Rationale: By calculating the infusion rate based on the given chart information, the correct value is 42 ml/hr. This rate ensures proper fluid administration to the laboring client. Choices B (38), C (48), and D (50) are incorrect as they do not align with the calculated infusion rate needed for the client's condition, as per the chart data provided.

4. On admission to the Emergency Department, a female client who was diagnosed with bipolar disorder 3 years ago reports that this morning she took a handful of medications and left a suicide note for her family. Which information is most important for the nurse to obtain?

• A. Which family member has the client's suicide note?
• B. When the client last took medications for bipolar disorder?
• C. What medications the client used for the suicide attempt?
• D. Whether the client has ever attempted suicide in the past?

Correct answer: C

Rationale: Identifying the specific medications taken during a suicide attempt is crucial for determining the appropriate treatment and assessing the potential toxicity or interactions. This information helps healthcare providers initiate the necessary interventions promptly. Option A is not as critical as knowing the medications used. Option B focuses on the timing of the last medication intake rather than the specific drugs taken for the overdose. Option D, while relevant, does not provide immediate actionable information compared to identifying the substances involved in the suicide attempt.

5. When gathering subjective data from a client, what intervention should the nurse implement first?

• A. Listen attentively
• B. Establish rapport
• C. List problems
• D. Clarify inferences

Correct answer: B

Rationale: Establishing rapport is the initial step the nurse should take when gathering subjective data from a client. Building trust and a good relationship with the client creates an environment where the client feels comfortable sharing accurate and honest information. Listening attentively is important but should come after rapport is established to enhance active listening. Listing problems and clarifying inferences are actions that occur later in the assessment process, after the nurse has established a good rapport and obtained a comprehensive understanding of the client's perspective. Therefore, option B is the correct answer.

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