Nursing Elites

1. A client at 38 weeks gestation with a history of herpes simplex virus 2 is being admitted. Which of the following questions is most appropriate to ask the client?

• A. Have your membranes ruptured?
• B. Do you have any active lesions?
• C. Are you positive for beta strep?
• D. How far apart are your contractions?

Correct answer: B

Rationale: The most appropriate question to ask a client with a history of herpes simplex virus 2 at 38 weeks gestation is whether they have any active lesions. Active herpes lesions during labor can necessitate a cesarean delivery to prevent neonatal transmission. Asking about ruptured membranes (choice A), beta strep status (choice C), or contraction timing (choice D) is important but not the priority when managing a client with a history of herpes simplex virus 2 due to the high risk of neonatal transmission.

2. When educating a patient about gabapentin use, what should the nurse include?

• A. It can cause sedation
• B. It can be taken with alcohol
• C. It is a pain reliever
• D. It has no side effects

Correct answer: A

Rationale: The correct answer is A: 'It can cause sedation.' Gabapentin is known to cause sedation, and patients should be advised about this side effect, especially regarding activities that require alertness. Choice B is incorrect because gabapentin should not be taken with alcohol as it can increase the risk of central nervous system depression. Choice C is incorrect because while gabapentin is used to treat nerve pain, it is not classified as a traditional pain reliever. Choice D is incorrect because gabapentin, like any medication, can have side effects, such as dizziness, drowsiness, and fatigue.

3. A nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which of the following findings should the nurse report to the healthcare provider?

• A. Urinary output of 40 mL/hr
• B. Respiratory rate of 10 breaths per minute
• C. Absent deep tendon reflexes
• D. Blood pressure of 150/90 mm Hg

Correct answer: B

Rationale: Magnesium sulfate can depress the central nervous system, leading to respiratory depression. A respiratory rate of 10 breaths per minute is below the normal range and requires immediate intervention. Urinary output of 40 mL/hr (Choice A) is within the normal range for a client receiving magnesium sulfate. Absent deep tendon reflexes (Choice C) are an expected finding due to the medication's effect on neuromuscular excitability. A blood pressure of 150/90 mm Hg (Choice D) is slightly elevated but not a priority concern compared to severe respiratory depression.

4. A nurse is assessing a client for signs of deep vein thrombosis (DVT). Which of the following findings should the nurse look for?

• A. Swelling in the limb
• B. Decreased heart rate
• C. Increased appetite
• D. Improved mobility

Correct answer: A

Rationale: The correct answer is A: Swelling in the limb. Swelling, particularly in one limb, is a common sign of deep vein thrombosis (DVT) and should be assessed. This swelling is often accompanied by pain, redness, and warmth in the affected area. Choices B, C, and D are incorrect because decreased heart rate, increased appetite, and improved mobility are not typically associated with DVT. The main focus in assessing for DVT is recognizing the signs and symptoms related to venous thrombosis.

5. A nurse is caring for a client prescribed hydromorphone for severe pain. The client's respiratory rate has decreased from 16 breaths per minute to 6. Which of the following medications should the nurse prepare to administer?

• A. Naloxone
• B. Flumazenil
• C. Activated charcoal
• D. Aluminum hydroxide

Correct answer: A

Rationale: Naloxone is the correct answer. Naloxone is the antidote for opioid overdose, including hydromorphone. Opioids can cause respiratory depression, and a significant decrease in respiratory rate from 16 to 6 breaths per minute indicates respiratory compromise. Naloxone should be administered promptly to reverse the effects of the opioid and restore normal respiratory function. Flumazenil (Choice B) is used to reverse the effects of benzodiazepines, not opioids. Activated charcoal (Choice C) is used for gastrointestinal decontamination in cases of overdose with certain substances, but it is not the appropriate intervention for opioid-induced respiratory depression. Aluminum hydroxide (Choice D) is an antacid and has no role in managing opioid overdose or respiratory depression.

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