Nursing Elites

1. A client with myasthenia gravis (MG) is receiving immunosuppressive therapy. Review of recent laboratory test results shows that the client’s serum magnesium level has decreased below the normal range. In addition to contacting the healthcare provider, what nursing action is most important?

• A. Check the visual difficulties
• B. Note the most recent hemoglobin level
• C. Assess for hand and joint pain
• D. Observe rhythm on telemetry monitor

Correct answer: D

Rationale: The correct answer is to observe the rhythm on the telemetry monitor. Decreased magnesium levels can lead to cardiac issues, such as arrhythmias. Monitoring the heart rhythm is crucial in this situation. Checking visual difficulties (choice A) is not directly related to the potential cardiac effects of low magnesium levels. Noting the hemoglobin level (choice B) and assessing for hand and joint pain (choice C) are not the priority when dealing with low magnesium levels and possible cardiac complications.

2. A 41-week gestation primigravida woman is admitted to labor and delivery for induction of labor. What finding should the nurse report to the healthcare provider before initiating the infusion of oxytocin?

• A. Fetal heart tones located in the upper right quadrant
• B. Biophysical profile results showing oligohydramnios
• C. Regular contractions occurring every 10 minutes
• D. Sterile vaginal exam revealing 3 cm dilation

Correct answer: B

Rationale: Oligohydramnios (low amniotic fluid) is a significant concern before starting oxytocin and should be reported to ensure safe labor induction. This finding can indicate potential fetal compromise and requires immediate evaluation. Fetal heart tones located in a specific quadrant, regular contractions, and cervical dilation are common assessments during labor but are not as critical as oligohydramnios in this scenario.

3. A client with deep vein thrombosis (DVT) in the left leg is on a heparin protocol. Which intervention is most important for the nurse to include in this client's plan of care?

• A. Observe for bleeding side effects related to heparin therapy.
• B. Assess blood pressure and heart rate at least every 4 hours.
• C. Measure calf girth to evaluate edema in the affected leg.
• D. Encourage mobilization to prevent pulmonary embolism.

Correct answer: A

Rationale: The correct answer is to 'Observe for bleeding side effects related to heparin therapy.' This is the most crucial intervention for a client with deep vein thrombosis (DVT) on a heparin protocol. Heparin, being an anticoagulant, increases the risk of bleeding as a side effect. Therefore, close monitoring for signs of bleeding, such as bruising, petechiae, or blood in stool or urine, is essential to prevent severe complications. While assessing blood pressure and heart rate (Choice B) is important, it is not as critical as monitoring for bleeding. Measuring calf girth (Choice C) may help evaluate edema but is not as vital as observing for bleeding complications. Encouraging mobilization (Choice D) is beneficial for preventing complications like pulmonary embolism, but in this scenario, monitoring for bleeding takes precedence due to the immediate risk associated with anticoagulant therapy.

4. When should the nurse conduct an Allen’s test?

• A. When obtaining pulmonary artery pressures
• B. To assess for the presence of a deep vein thrombus in the leg
• C. Just before arterial blood gases are drawn peripherally
• D. Prior to attempting a cardiac output calculation

Correct answer: C

Rationale: The correct time to conduct an Allen’s test is just before arterial blood gases are drawn peripherally. This test is performed to assess the adequacy of collateral circulation in the hand before obtaining arterial blood gases. Choice A is incorrect because an Allen’s test is not specifically done when obtaining pulmonary artery pressures. Choice B is incorrect because an Allen’s test is not used to assess deep vein thrombosis. Choice D is incorrect because an Allen’s test is not done specifically before attempting a cardiac output calculation.

5. The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing actions should the nurse assign to the PN? (Select all that apply)

• A. Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus (DM)
• B. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty
• C. Perform daily surgical dressing change for a client who had an abdominal hysterectomy
• D. Initiate patient-controlled analgesia (PCA) pumps for two clients immediately postoperative

Correct answer: B

Rationale: The correct answer is B. Obtaining postoperative vital signs for a client one day following unilateral knee arthroplasty is a task within the scope of practice for a practical nurse (PN) and contributes to the client's recovery. Administering insulin (Choice A) involves medication administration, which typically requires a higher level of nursing education. Performing daily surgical dressing changes (Choice C) after an abdominal hysterectomy involves wound care management that is usually beyond the scope of practice for a PN. Initiating patient-controlled analgesia pumps (Choice D) is a complex nursing intervention that requires specialized training and knowledge, exceeding the typical responsibilities of a PN.

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