Nursing Elites

1. Two hours after delivering a 9-pound infant, a client saturates a perineal pad every 15 minutes. Although an IV containing Pitocin is infusing, her uterus remains boggy, even with massage. The healthcare provider prescribes methylergometrine maleate (Methergine) 0.2 mg IM STAT. Which complication should the nurse be alert to this client developing?

• A. Decreased respiratory rate
• B. Increased temperature
• C. Tachycardia
• D. Hypertension

Correct answer: D

Rationale: The correct answer is D: Hypertension. Methylergometrine maleate (Methergine) is a medication used to prevent or control postpartum hemorrhage by causing uterine contractions. One of the potential side effects is hypertension. Therefore, the nurse should closely monitor the client's blood pressure after administering Methergine. Choices A, B, and C are incorrect because Methergine is not known to cause decreased respiratory rate, increased temperature, or tachycardia.

2. Which client should the nurse assess frequently because of the risk for overflow incontinence?

• A. A client who is bedfast, with increased serum BUN and creatinine levels
• B. A client with hematuria and decreasing hemoglobin and hematocrit levels
• C. A client who has a history of frequent urinary tract infections
• D. A client who is confused and frequently forgets to go to the bathroom

Correct answer: A

Rationale: The correct answer is A. Bedfast clients with increased serum BUN and creatinine levels are at high risk for overflow incontinence. This occurs due to decreased bladder function and reduced ability to sense bladder fullness, leading to the bladder overfilling and leaking urine. Choice B describes symptoms related to possible urinary tract infections or renal issues, but these do not directly indicate overflow incontinence. Choice C, a history of frequent urinary tract infections, may suggest other urinary issues but not specifically overflow incontinence. Choice D, a confused client who forgets to go to the bathroom, is more indicative of functional incontinence rather than overflow incontinence.

3. During discharge teaching, the nurse discusses the parameters for weight monitoring with a client recently diagnosed with heart failure (HF). Which information is most important for the client to acknowledge?

• A. Weigh at the same time every day
• B. Report weight gain of 2 pounds (0.9kg) in 24 hours
• C. Maintain a daily weight record
• D. Limit dietary salt intake

Correct answer: B

Rationale: The correct answer is B. Reporting a weight gain of 2 pounds in 24 hours is crucial for detecting fluid retention or worsening heart failure. This rapid weight gain indicates possible fluid overload, which can be a sign of worsening HF. Option A is not as critical as the timing of weighing can vary. Option C is important for tracking trends but does not emphasize the significance of a sudden weight gain. Option D is relevant for managing HF but does not address the immediate need for reporting rapid weight gain.

4. The charge nurse is making assignments for clients on an endocrine unit. Which client is best to assign to a new graduate nurse?

• A. A female adult with hyperthyroidism who is returning to the unit after a thyroidectomy
• B. A male adult with Cushing's syndrome who reports a headache and visual disturbances
• C. An older man with Addison's disease who is diaphoretic and has hand tremors
• D. A perimenopausal woman with Graves' disease who is nervous and has exophthalmos

Correct answer: A

Rationale: A new graduate nurse can manage the care of a stable client returning from a thyroidectomy. Choice B is not suitable for a new graduate nurse as it involves complex symptoms of Cushing's syndrome that require more experience and knowledge. Choice C presents a client with acute manifestations of Addison's disease, which may be challenging for a new graduate nurse. Choice D involves a client with Graves' disease experiencing nervousness and exophthalmos, which also require a higher level of expertise to manage effectively.

5. A male client with hypertension, who received new antihypertensive prescriptions at his last visit, returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106, and he admits that he has not been taking the prescribed medication because the drugs make him 'feel bad.' In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition?

• A. Feed the client a snack
• B. Empty the urinary drainage bag
• C. Offer the client oral fluids
• D. Stroke secondary to hemorrhage

Correct answer: D

Rationale: Elevated blood pressure, if left uncontrolled, significantly increases the risk of stroke secondary to hemorrhage and other cardiovascular events. This condition can lead to serious complications due to the increased pressure on the blood vessels in the brain. Choices A, B, and C are unrelated to the potential pathophysiological consequences of uncontrolled hypertension and are not the primary concern in this scenario.

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