Nursing Elites

1. A nurse is assessing a client who is at 34 weeks of gestation and has gestational hypertension. Which of the following findings should the nurse report to the provider?

• A. Blood pressure of 140/90 mm Hg
• B. Fasting blood glucose of 120 mg/dL
• C. Urinary output of 40 mL/hr
• D. Weight gain of 2.3 kg (5 lb) in 1 week

Correct answer: D

Rationale: A weight gain of 2.3 kg (5 lb) in 1 week can indicate worsening gestational hypertension and should be reported to the provider. Sudden weight gain in a client with gestational hypertension can be a sign of fluid retention, which could worsen the hypertension and lead to complications like preeclampsia. The other options, blood pressure of 140/90 mm Hg, fasting blood glucose of 120 mg/dL, and urinary output of 40 mL/hr, are within normal limits for a client with gestational hypertension and do not pose an immediate concern that requires reporting to the provider.

2. A nurse is caring for a client who has a prescription for enoxaparin. Which of the following actions should the nurse take?

• A. Inject the medication into the deltoid muscle
• B. Inject the medication deep into subcutaneous tissue
• C. Massage the injection site for 2 minutes after administration
• D. Insert the needle at a 10-degree angle

Correct answer: B

Rationale: The correct action the nurse should take when administering enoxaparin is to inject the medication deep into subcutaneous tissue. This method helps ensure proper absorption of the medication and prevents tissue irritation. Injecting into the deltoid muscle (Choice A) is not recommended for enoxaparin administration. Massaging the injection site (Choice C) can lead to tissue damage and bruising. Inserting the needle at a 10-degree angle (Choice D) is not the correct technique for administering enoxaparin.

3. A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following actions should the nurse take?

• A. Administer haloperidol as prescribed.
• B. Keep the client in a supine position.
• C. Administer lorazepam as prescribed.
• D. Encourage the client to drink fluids with meals.

Correct answer: C

Rationale: The correct action the nurse should take when caring for a client experiencing acute alcohol withdrawal is to administer lorazepam as prescribed. Lorazepam is a benzodiazepine used to prevent seizures and manage agitation in clients undergoing alcohol withdrawal. Administering haloperidol (Choice A) is not recommended in alcohol withdrawal as it may lower the seizure threshold. Keeping the client in a supine position (Choice B) is not specifically indicated in managing alcohol withdrawal. Encouraging the client to drink fluids with meals (Choice D) is important for hydration but does not address the acute symptoms of alcohol withdrawal.

4. A nurse is caring for a client who is receiving packed RBCs. Which of the following actions should the nurse take?

• A. Monitor the client's blood glucose level every hour
• B. Administer the blood using a microdrip set
• C. Assess the client's vital signs every 2 hours
• D. Infuse the blood within 4 hours

Correct answer: D

Rationale: The correct answer is to infuse the blood within 4 hours. This is crucial to prevent bacterial contamination and hemolysis during blood transfusions. Monitoring the client's blood glucose level every hour (Choice A) is not directly related to packed RBC transfusions. Administering the blood using a microdrip set (Choice B) may be appropriate for specific medications but is not a requirement for packed RBC transfusions. Assessing the client's vital signs every 2 hours (Choice C) is important for monitoring the client's overall condition but is not as time-sensitive as ensuring the timely infusion of packed RBCs.

5. A client who is taking phenytoin is being taught about contraceptive options. Which of the following statements should the nurse make?

• A. You should use a backup method of birth control while taking phenytoin.
• B. Phenytoin can decrease the effectiveness of oral contraceptives.
• C. You should stop taking phenytoin while using oral contraceptives.
• D. Phenytoin can increase the effectiveness of oral contraceptives.

Correct answer: B

Rationale: The correct answer is B. Phenytoin can decrease the effectiveness of oral contraceptives, so it is important to inform the client about this interaction. Using an additional form of contraception, such as a backup method, is recommended to ensure adequate protection against pregnancy. Choice A is incorrect because it lacks specificity about the decrease in effectiveness of oral contraceptives caused by phenytoin. Choice C is incorrect as it suggests stopping phenytoin use while using oral contraceptives, which is not the appropriate action. Choice D is incorrect as phenytoin is known to decrease, not increase, the effectiveness of oral contraceptives.

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