Nursing Elites

1. A nurse is assessing a client for potential drug interactions. Which of the following factors should the nurse consider?

• A. Client's diet
• B. Client's age
• C. Client's genetic background
• D. All of the above

Correct answer: D

Rationale: Correct! All of these factors should be considered when assessing a client for potential drug interactions. The client's diet can interact with certain medications, the client's age can affect metabolism and drug sensitivity, and genetic background can impact how the body processes medications. Therefore, it is essential for the nurse to take into account all these factors to ensure safe and effective drug therapy. Choices A, B, and C are incorrect because each of these factors alone can contribute to potential drug interactions, making it crucial to consider all of them together.

2. A nurse is assessing a client 2 hours after a vaginal delivery and notes that the client's uterus is boggy and displaced to the right. Which of the following interventions should the nurse perform first?

• A. Assist the client to void
• B. Massage the uterus
• C. Administer oxytocin
• D. Encourage breastfeeding

Correct answer: A

Rationale: A boggy and displaced uterus is often a sign of bladder distention, which can prevent the uterus from contracting effectively. The priority intervention is to assist the client to void. By emptying the bladder, the uterus can return to midline and become firm. Massaging the uterus or administering oxytocin may be necessary but should come after addressing the bladder distention. Encouraging breastfeeding is important for uterine contraction but is not the priority in this situation.

3. A nurse is assessing a male adolescent client who has heart failure. Based on the client’s chart, which of the following actions should the nurse plan to take?

• A. Withhold spironolactone
• B. Administer ferrous sulfate
• C. Administer furosemide
• D. Withhold digoxin

Correct answer: C

Rationale: The correct answer is to administer furosemide. Furosemide is a diuretic commonly used in heart failure to manage fluid retention, helping alleviate symptoms like edema and shortness of breath. Withholding spironolactone, a potassium-sparing diuretic, could lead to electrolyte imbalances. Administering ferrous sulfate is used to treat iron deficiency anemia, not heart failure. Withholding digoxin, a medication used in heart failure to improve heart function, can worsen the client's condition.

4. A nurse is caring for a client who is receiving oxytocin to augment labor. The client has an intrauterine pressure catheter and an internal fetal scalp electrode for monitoring. Which of the following is an indication that the nurse should discontinue the infusion?

• A. Contraction frequency every 3 minutes
• B. Contraction duration of 100 seconds
• C. Fetal heart rate with moderate variability
• D. Fetal heart rate of 118/min

Correct answer: B

Rationale: A contraction duration of 100 seconds indicates potential uterine hyperstimulation, which can lead to fetal distress and decreased uterine perfusion. Prolonged contractions may reduce oxygen supply to the fetus, putting it at risk. Discontinuing the oxytocin infusion is crucial to prevent adverse effects on both the mother and the fetus. The other options do not raise immediate concerns that would necessitate discontinuing the oxytocin infusion. Contraction frequency every 3 minutes is within a normal range. Fetal heart rate with moderate variability and a rate of 118/min are both reassuring signs of fetal well-being.

5. A healthcare professional is assessing a client with heart failure. Which of the following signs should the healthcare professional monitor for?

• A. Peripheral edema
• B. Tachycardia
• C. Bradycardia
• D. Hypotension

Correct answer: A

Rationale: In heart failure, the accumulation of fluid can lead to peripheral edema, which is swelling in the extremities. This is a common sign that healthcare professionals should monitor for. While tachycardia (increased heart rate), bradycardia (decreased heart rate), and hypotension (low blood pressure) can also occur in heart failure, they are not the primary signs typically associated with this condition. Therefore, peripheral edema is the most relevant sign to monitor in this case.

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