Nursing Elites

1. Which nursing intervention has the highest priority for a multigravida who delivered an hour ago?

• A. Maintain cold packs to the perineum for 24 hours.
• B. Assess the client's pain level frequently.
• C. Observe for appropriate interaction with the infant.
• D. Assess fundal tone and lochia flow.

Correct answer: D

Rationale: Assessing fundal tone and lochia flow is crucial in the immediate postpartum period to detect postpartum hemorrhage, a life-threatening complication. Monitoring these parameters allows for early identification of excessive bleeding, enabling prompt intervention. While maintaining cold packs to the perineum, assessing pain levels, and observing for appropriate interaction with the infant are important aspects of postpartum care, assessing fundal tone and lochia flow takes precedence due to its direct relevance to identifying and managing a potential emergency situation.

2. A client with urticaria due to environmental allergies is taking diphenhydramine (Benadryl). Which complaint should the nurse identify as a side effect of this OTC medication?

• A. Nausea and indigestion.
• B. Hypersalivation.
• C. Eyelid and facial twitching.
• D. Increased appetite.

Correct answer: A

Rationale: The correct answer is A: Nausea and indigestion. Diphenhydramine, an antihistamine, commonly causes gastrointestinal side effects such as nausea and indigestion. These symptoms are often reported by individuals taking this medication. Choices B, C, and D are incorrect because hypersalivation, eyelid and facial twitching, and increased appetite are not typically associated with diphenhydramine use.

3. A female client reports that she drank a liter of a solution to cleanse her intestines but vomited immediately. How many ml of fluid intake should the nurse document?

• A. 240 ml
• B. 500 ml
• C. 760 ml
• D. 1000 ml

Correct answer: C

Rationale: The correct answer is 760 ml. After vomiting 240 ml (1 cup), the nurse should document the remaining 760 ml as the fluid intake. Choice A (240 ml) is the amount vomited, not the total intake. Choice B (500 ml) and Choice D (1000 ml) are the total intake, not considering the vomiting.

4. A client with chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. Which laboratory value is most concerning?

• A. Serum potassium of 6.5 mEq/L
• B. Serum bicarbonate of 18 mEq/L
• C. Serum glucose of 350 mg/dl
• D. Serum sodium of 135 mEq/L

Correct answer: A

Rationale: A serum potassium level of 6.5 mEq/L is concerning in a client with COPD exacerbation as it may lead to life-threatening arrhythmias, requiring immediate intervention. Hyperkalemia can cause cardiac arrhythmias, which pose a significant risk to the patient's life. Options B, C, and D are not typically associated with immediate life-threatening risks in the context of a COPD exacerbation.

5. A client with hyperthyroidism is admitted to the postoperative unit after subtotal thyroidectomy. Which of the client's serum laboratory values requires intervention by the nurse?

• A. Total calcium 5.0 mg/dL.
• B. Serum sodium 140 mEq/L.
• C. Serum potassium 4.0 mEq/L.
• D. Serum glucose 90 mg/dL.

Correct answer: A

Rationale: The correct answer is A. A calcium level of 5.0 mg/dL is critically low and could indicate hypoparathyroidism, a possible complication after thyroidectomy. Low calcium levels can lead to tetany, seizures, and cardiac dysrhythmias, requiring immediate intervention. Choices B, C, and D fall within the normal range and do not require immediate intervention in this scenario.

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