Nursing Elites

1. An unlicensed assistive personnel (UAP) reports to the charge nurse that a client who delivered a 7-pound infant 12 hours ago is reporting a severe headache. The client’s blood pressure is 110/70 mmHg, respiratory rate is 18 breaths/min, heart rate is 74 beats/min, and temperature is 98.6°F (37°C). What action should the charge nurse implement first?

• A. Notify the healthcare provider of the assessment findings.
• B. Administer analgesics as prescribed.
• C. Increase the client’s fluid intake.
• D. Monitor the client’s vital signs every hour.

Correct answer: A

Rationale: A severe headache post-delivery could indicate a serious condition such as preeclampsia or a spinal headache, which requires immediate medical attention. Notifying the healthcare provider of the assessment findings allows for prompt evaluation and appropriate management of the client's condition.

2. A two-year-old child with heart failure (HF) is admitted for replacement of a graft for coarctation of the aorta. Prior to administering the next dose of digoxin (Lanoxin), the nurse obtains an apical heart rate of 128 bpm. What action should the nurse take?

• A. Determine the pulse deficit
• B. Administer the scheduled dose
• C. Calculate the safe dose range
• D. Review the serum digoxin level

Correct answer: B

Rationale: The correct action for the nurse to take is to administer the scheduled dose of digoxin. A heart rate of 128 bpm in a two-year-old child with heart failure falls within the safe range for digoxin administration. It indicates that the child's heart rate is not excessively low, which could be a concern for administering digoxin. Therefore, proceeding with the scheduled dose is appropriate in this scenario. Determining the pulse deficit (Choice A) is not necessary in this situation as the heart rate is already obtained. Calculating the safe dose range (Choice C) is not required as the heart rate is within the safe range. Reviewing the serum digoxin level (Choice D) is not needed at this point since the heart rate indicates that administering the next dose is appropriate.

3. The healthcare provider prescribes oxytocin 2 milliunits/minute to induce labor for a client at 41-weeks gestation. The nurse initiates an infusion of Ringer’s Lactate solution 1000 mL with oxytocin 10 units. How many mL/hour should the nurse program the infusion pump?

• A. 12 mL/hour
• B. 2 mL/hour
• C. 22 mL/hour
• D. 42 mL/hour

Correct answer: A

Rationale: To calculate the infusion rate in mL/hour, first, convert 2 milliunits/minute to milliunits/hour by multiplying by 60 to get 120 milliunits/hour. Then, calculate the mL/hour using the formula: milliunits/hour (120) × total volume (1000 mL) ÷ units in IV solution (10 units) = 1200 mL/hour. Therefore, the nurse should program the infusion pump to deliver 12 mL/hour to provide the prescribed dose of oxytocin. Choice B is incorrect as it does not reflect the correct calculation. Choice C is incorrect as it is not derived from the correct formula. Choice D is incorrect as it is not the result of the accurate calculation based on the provided information.

4. During a routine prenatal health assessment for a client in her third trimester, the client reports that she had fluid leakage on her way to the appointment. Which technique should the nurse implement to evaluate the leakage?

• A. Insert a straight urinary catheter to drain the bladder.
• B. Scan the bladder for urinary retention.
• C. Palpate the suprapubic area for fetal head position.
• D. Test the fluid with a nitrazine strip.

Correct answer: D

Rationale: Testing the fluid with a nitrazine strip is the appropriate technique to differentiate between amniotic fluid and urine. This test helps in determining if the fluid leakage is amniotic fluid, which is crucial for guiding further management and ensuring appropriate care for the client during the third trimester of pregnancy. Inserting a straight urinary catheter to drain the bladder (Choice A) is unnecessary and invasive in this scenario as the concern is fluid leakage, not urinary retention. Scanning the bladder for urinary retention (Choice B) is also not indicated since the client reported fluid leakage, not retention. Palpating the suprapubic area for fetal head position (Choice C) is unrelated to assessing fluid leakage and not the appropriate technique in this situation.

5. A client is admitted to the postpartum unit and tells the nurse she had rheumatic fever as a child, which resulted in some 'heart damage'. The nurse knows that this client is at particular risk for developing heart failure during the immediate postpartum period. Based on the client's history, which nursing problem has the highest priority?

• A. Nausea and vomiting.
• B. Risk for infection.
• C. Sleep deprivation.
• D. Fluid volume excess.

Correct answer: D

Rationale: Fluid volume excess is a priority concern in this client, as heart damage from rheumatic fever can impair the heart's ability to manage increased blood volume postpartum, leading to potential heart failure. Monitoring and managing fluid volume status are crucial to prevent complications in this high-risk client. Choices A, B, and C are not the highest priority in this situation. Nausea and vomiting, risk for infection, and sleep deprivation are important but do not pose an immediate threat to the client's physiologic stability compared to the risk of heart failure due to fluid volume excess.

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