Nursing Elites

1. When assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate, which finding should the nurse report to the health care provider immediately?

• A. The bibasilar breath sounds are decreased.
• B. The patellar and triceps reflexes are absent.
• C. The patient has been sleeping most of the day.
• D. The patient reports feeling 'sick to my stomach.'

Correct answer: B

Rationale: The correct answer is B because the absence of patellar and triceps reflexes indicates potential magnesium toxicity, requiring immediate intervention. Nausea and lethargy are common side effects of elevated magnesium levels and should be reported, but they are not as critical as the loss of deep tendon reflexes. Decreased breath sounds suggest the need for coughing and deep breathing to prevent atelectasis, which is important but not as urgent as addressing magnesium toxicity.

2. The nurse observes an unlicensed assistive personnel (UAP) who is providing a total bed bath for a confused and lethargic client. The UAP is soaking the client's foot in a basin of warm water placed on the bed. What action should the nurse take?

• A. Remove the basin of water from the client's bed immediately
• B. Remind the UAP to dry between the client's toes completely
• C. Advise the UAP that this procedure is damaging to the skin
• D. Add skin cream to the basin of water while the foot is soaking

Correct answer: B

Rationale: Choice (B) is the correct action for the nurse to take in this situation. Ensuring that the UAP dries between the client's toes completely is crucial to prevent skin breakdown due to excessive moisture. While keeping the client's feet clean is important, maintaining dryness is paramount for skin integrity. Choices (A), (C), and (D) are incorrect: (A) removing the basin of water immediately may disrupt the care process without addressing the root issue, (C) advising the UAP that the procedure is damaging to the skin is not as immediate or specific to the observed problem, and (D) adding skin cream to the water may not address the need for drying the client's toes thoroughly.

3. What is the first action the nurse should take when a patient complains of acute chest pain and dyspnea soon after insertion of a centrally inserted IV catheter?

• A. Notify the health care provider.
• B. Offer reassurance to the patient.
• C. Auscultate the patient’s breath sounds
• D. Give the prescribed PRN morphine sulfate IV

Correct answer: C

Rationale: The correct first action for the nurse to take when a patient complains of acute chest pain and dyspnea after the insertion of a centrally inserted IV catheter is to auscultate the patient's breath sounds. This is important to assess for any potential complications such as embolism or pneumothorax, which can present with such symptoms. Auscultation can provide immediate information on the patient's respiratory status and guide further interventions. Notifying the health care provider, offering reassurance, or administering morphine should only be considered after assessing the patient's condition through auscultation.

4. A patient who has small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the healthcare provider about which assessment finding?

• A. Reported weight gain
• B. Serum hematocrit of 42%
• C. Serum sodium level of 120 mEq/L
• D. Total urinary output of 280 mL during the past 8 hours

Correct answer: C

Rationale: The correct answer is C, a serum sodium level of 120 mEq/L. Hyponatremia is the most important finding to report in SIADH. SIADH causes water retention and a decrease in serum sodium levels. Hyponatremia can lead to confusion and other central nervous system effects and requires treatment. Adequate kidney function is indicated by a urinary output of at least 30 mL/hr. A hematocrit level of 42% is normal. Weight gain is expected due to water retention in SIADH.

5. The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the procedure?

• A. Experiences facial swelling after eating crab
• B. Reports left chest wall pain prior to the admission
• C. Verbalizes a fear of being in a confined space
• D. Drank a glass of water

Correct answer: A

Rationale: The correct answer is A. Allergy to shellfish can indicate a potential allergy to iodine, which is used in contrast dye for the procedure. This must be explored further to prevent an allergic reaction. Choice B is not directly related to the angioplasty procedure. Choice C pertains to claustrophobia, which can be addressed but is not directly related to the safety of the procedure. Choice D is a routine activity and does not pose a risk to the client during the procedure.

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