Nursing Elites

1. A nurse is assessing a client who is receiving packed RBCs. Which of the following findings indicate fluid overload?

• A. Low back pain
• B. Dyspnea
• C. Hypotension
• D. Thready pulse

Correct answer: B

Rationale: The correct answer is B: Dyspnea. Dyspnea, or difficulty breathing, is a common sign of fluid overload in a client receiving packed RBCs. When fluid accumulates in the lungs due to overload, it can lead to respiratory distress. This finding requires prompt intervention to prevent further complications. Choices A, C, and D are incorrect: A) Low back pain is not typically associated with fluid overload; C) Hypotension refers to low blood pressure and is not a typical finding in fluid overload; D) Thready pulse may indicate poor perfusion but is not a direct indicator of fluid overload.

2. A nurse is caring for a client who is in labor and requires augmentation of labor. Which of the following conditions should the nurse recognize as a contraindication to the use of oxytocin?

• A. Diabetes mellitus
• B. Shoulder presentation
• C. Postterm with oligohydramnios
• D. Chorioamnionitis

Correct answer: B

Rationale: Shoulder presentation is a contraindication for oxytocin because it can increase the risk of complications during labor, such as shoulder dystocia. Diabetes mellitus (Choice A) is not a contraindication for the use of oxytocin. Postterm with oligohydramnios (Choice C) and chorioamnionitis (Choice D) may actually necessitate the use of oxytocin to induce or augment labor for the well-being of the mother and baby.

3. A client is 4 hours postpartum. Which of the following interventions should be implemented to prevent postpartum hemorrhage?

• A. Monitor for signs of infection.
• B. Massage the uterus every 4 hours.
• C. Apply ice packs to the perineum.
• D. Administer methylergonovine IM.

Correct answer: D

Rationale: Administering methylergonovine intramuscularly helps contract the uterus, reducing the risk of postpartum hemorrhage. Monitoring for signs of infection (Choice A) is important but not directly related to preventing postpartum hemorrhage. Uterine massage (Choice B) is beneficial to prevent uterine atony, but methylergonovine is a more specific intervention to prevent hemorrhage. Applying ice packs to the perineum (Choice C) is helpful for perineal pain and swelling, not for preventing postpartum hemorrhage.

4. A nurse is assessing a client who is receiving furosemide for heart failure. Which of the following findings is the priority to report to the provider?

• A. Blood pressure of 98/58 mm Hg
• B. Urine output of 50 mL/hr
• C. Serum potassium level of 3.2 mEq/L
• D. Weight loss of 0.5 kg (1.1 lb) in 24 hours

Correct answer: C

Rationale: The correct answer is C. A serum potassium level of 3.2 mEq/L indicates hypokalemia, a potential complication of furosemide therapy, and should be reported immediately. Hypokalemia can lead to serious cardiac dysrhythmias. Choices A, B, and D are important assessments but are not as critical as managing serum potassium levels in a client receiving furosemide for heart failure.

5. Which medication is commonly prescribed for a patient with hypertension?

• A. Lisinopril
• B. Metformin
• C. Atorvastatin
• D. Aspirin

Correct answer: A

Rationale: The correct answer is Lisinopril. Lisinopril is an ACE inhibitor commonly prescribed to patients with hypertension to manage their blood pressure. Metformin is used to treat type 2 diabetes, not hypertension (choice B). Atorvastatin is a statin used to lower cholesterol levels, not primarily prescribed for hypertension (choice C). Aspirin is used for its antiplatelet effects and in preventing cardiovascular events, but it is not a first-line treatment for hypertension (choice D). Therefore, Lisinopril is the most suitable choice for a patient with hypertension.

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