Nursing Elites

1. A client has severe preeclampsia and is receiving magnesium sulfate IV. Which of the following findings should the nurse identify and report as signs of magnesium sulfate toxicity? (Select all that apply)

• A. Respirations less than 12/min
• B. Urinary output less than 25 mL/hr
• C. Decreased level of consciousness
• D. All of the above

Correct answer: D

Rationale: Signs of magnesium sulfate toxicity include respirations less than 12/min, urinary output less than 25 mL/hr, and decreased level of consciousness. These signs indicate potential overdose of magnesium sulfate and require immediate attention to prevent further complications. Reporting these signs promptly is crucial to ensure the client's safety and well-being. Choice D, 'All of the above,' is the correct answer as all the listed findings are indicative of magnesium sulfate toxicity. Choices A, B, and C individually represent different signs of toxicity, making them incorrect on their own. Therefore, the nurse should be vigilant in identifying and reporting all these signs to prevent adverse outcomes.

2. A healthcare provider is preparing to administer vitamin K by IM injection to a newborn. The medication should be administered into which of the following muscles?

• A. Vastus lateralis
• B. Ventrogluteal
• C. Dorsogluteal
• D. Deltoid

Correct answer: A

Rationale: Vitamin K is typically administered in the vastus lateralis muscle of a newborn to prevent bleeding disorders. The vastus lateralis muscle is the preferred site for IM injections in infants due to its size and accessibility, allowing for easy and safe administration. The ventrogluteal and dorsogluteal sites are more commonly used in adults due to better muscle mass and less risk of injury to nearby structures. The deltoid muscle is typically used for older children and adults for IM injections, as it is a well-developed muscle suitable for injections in these populations.

3. When caring for a client in labor, which of the following infections can be treated during labor or immediately following birth? (Select all that apply)

• A. Gonorrhea
• B. Chlamydia
• C. HIV
• D. All of the Above

Correct answer: D

Rationale: Infections such as gonorrhea, chlamydia, and HIV can be treated during labor or immediately following birth to prevent transmission to the newborn. It is crucial to identify and treat these infections promptly to reduce the risk of vertical transmission to the infant. Therefore, all the given options are correct as they can be treated during labor or immediately following birth to prevent transmission to the newborn. Other choices are incorrect because only gonorrhea, chlamydia, and HIV can be effectively treated during labor or immediately after birth to prevent vertical transmission.

4. A client in a prenatal clinic is receiving education from a nurse and mentions, 'I don't like milk.' Which of the following foods should the nurse recommend as a good source of calcium?

• A. Dark green leafy vegetables
• B. Deep red or orange vegetables
• C. White bread and rice
• D. Meat, poultry, and fish

Correct answer: A

Rationale: Dark green leafy vegetables are rich in calcium, making them an excellent alternative source for individuals who dislike or cannot consume dairy products. Calcium is crucial for bone health, particularly during pregnancy, to support the developing fetus and maintain the mother's bone strength. Therefore, recommending dark green leafy vegetables ensures the client receives an adequate intake of calcium despite not liking milk. Choice B, deep red or orange vegetables, are not typically high in calcium. Choice C, white bread and rice, are not significant sources of calcium. Choice D, meat, poultry, and fish, are good sources of protein but do not provide as much calcium as dark green leafy vegetables.

5. When caring for a client suspected of having hyperemesis gravidarum, which finding is a manifestation of this condition?

• A. Hgb 12.2 g/dL
• B. Urine ketones present
• C. Alanine aminotransferase 20 IU/L
• D. Blood glucose 114 mg/dL

Correct answer: B

Rationale: The correct answer is B: Urine ketones present. The presence of urine ketones indicates dehydration, which is a common manifestation of hyperemesis gravidarum. Hyperemesis gravidarum is characterized by severe nausea, vomiting, weight loss, and electrolyte imbalances due to dehydration. Monitoring for ketonuria helps assess the degree of dehydration in clients with this condition. Choices A, C, and D are incorrect because hemoglobin level, alanine aminotransferase level, and blood glucose level are not specific manifestations of hyperemesis gravidarum. While these laboratory values may be abnormal in some cases, they are not typically used to diagnose or assess the condition.

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