Nursing Elites

1. A healthcare professional is reviewing the arterial blood gas results for a client in the ICU who has kidney failure and determines the client has respiratory acidosis. Which of the following findings should the healthcare professional expect?

• A. Widened QRS complexes
• B. Hyperactive deep tendon reflexes
• C. Bounding peripheral pulses
• D. Warm, flushed skin

Correct answer: A

Rationale: Respiratory acidosis is characterized by an increase in carbon dioxide levels in the blood, leading to acidosis. This condition can affect the heart's electrical conduction system, resulting in widened QRS complexes on an electrocardiogram (ECG). Hyperactive deep tendon reflexes, bounding peripheral pulses, and warm, flushed skin are not typically associated with respiratory acidosis.

2. A nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

• A. Provide a sitz bath to a client who has a fourth-degree laceration and is 2 days postpartum.
• B. Observe an area of redness on the breast of a client who is 1 day postpartum.
• C. Monitor vital signs during admission of a client who has gestational hypertension.
• D. Change the perineal pad of a client who just transferred from labor and delivery.

Correct answer: A

Rationale: Delegating the task of providing a sitz bath to a client with a fourth-degree laceration and who is 2 days postpartum to the assistive personnel (AP) is appropriate. This task involves assisting the client with personal hygiene and comfort measures that can be safely performed by the AP under the supervision and direction of the nurse. Tasks like observing redness on the breast, monitoring vital signs during admission for gestational hypertension, and changing perineal pads may require a higher level of assessment and nursing judgment, making them more appropriate for the nurse to perform.

3. A client is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (Select one that doesn't apply.)

• A. Elevate the head of the bed to at least 30�.
• B. Apply restraints if the client becomes agitated.
• C. Administer pantoprazole as prescribed.
• D. Reposition the endotracheal tube to the opposite side of the mouth daily.

Correct answer: D

Rationale: Repositioning the endotracheal tube to the opposite side of the mouth daily is not a standard practice in preventing complications in a client receiving positive-pressure mechanical ventilation. This action may disrupt the secure placement of the endotracheal tube and increase the risk of complications. Elevating the head of the bed to at least 30� helps prevent aspiration and ventilator-associated pneumonia. Applying restraints if the client becomes agitated helps maintain the safety of the client by preventing self-extubation or accidental dislodgement of tubes. Administering pantoprazole as prescribed helps prevent stress ulcers, a common complication in critically ill patients on mechanical ventilation.

4. A client is being assessed for postpartum infection. Which of the following findings should indicate to the healthcare provider that the client requires further evaluation for endometritis?

• A. Localized area of breast tenderness
• B. Pelvic pain
• C. Vaginal discharge with foul odor
• D. Hematuria

Correct answer: B

Rationale: Pelvic pain is a common symptom of endometritis, which is an infection of the uterine lining. It is an important finding that warrants further evaluation. Localized area of breast tenderness may indicate mastitis, vaginal discharge with a foul odor could suggest a vaginal infection, and hematuria points towards a urinary tract issue, but they are not specific to endometritis.

5. A client with severe preeclampsia is receiving magnesium sulfate IV at 2 g/hr. Which of the following findings indicates that it is safe to continue the infusion?

• A. Diminished deep-tendon reflexes
• B. Respiratory rate of 16/min
• C. Urine output of 50 mL in 4 hours
• D. Heart rate of 56/min

Correct answer: B

Rationale: A respiratory rate of 16/min within the normal range is an essential parameter to monitor when administering magnesium sulfate, as respiratory depression is a potential adverse effect. Diminished deep-tendon reflexes may indicate magnesium toxicity, warranting immediate intervention. A urine output of 50 mL in 4 hours is below the expected amount, suggesting decreased kidney perfusion, which can be exacerbated by magnesium sulfate. A heart rate of 56/min is bradycardic and may indicate magnesium toxicity, requiring assessment and possible discontinuation of the infusion.

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