Nursing Elites

1. A client with preeclampsia is receiving magnesium sulfate intravenously. What action should the nurse take if the client develops toxicity?

• A. Position the client supine
• B. Prepare an IV bolus of dextrose 5%
• C. Administer calcium gluconate IV
• D. Administer methylergonovine IM

Correct answer: C

Rationale: In cases of magnesium sulfate toxicity, calcium gluconate is the antidote as it helps reverse the effects. Positioning the client supine (Choice A) may not directly address magnesium sulfate toxicity. Administering dextrose 5% (Choice B) is not the correct intervention for magnesium sulfate toxicity. Methylergonovine IM (Choice D) is used to manage postpartum hemorrhage, not magnesium sulfate toxicity.

2. A nurse is preparing to administer a dose of warfarin. Which of the following should the nurse do?

• A. Check INR levels
• B. Administer it with food
• C. Monitor blood glucose
• D. Assess liver function

Correct answer: A

Rationale: The correct answer is to check INR levels. Before administering warfarin, it is crucial to check the INR levels to ensure they are within the therapeutic range. This helps to prevent complications such as bleeding or clotting. Choice B, administering it with food, is incorrect as warfarin should typically be taken on an empty stomach. Choice C, monitoring blood glucose, is unrelated to the administration of warfarin. Choice D, assessing liver function, is important but not the immediate action required before administering warfarin.

3. A client has been diagnosed with tuberculosis. Which of the following precautions should the nurse initiate to prevent transmission of the disease?

• A. Contact precautions
• B. Airborne precautions
• C. Droplet precautions
• D. Protective environment

Correct answer: B

Rationale: Tuberculosis is spread through small droplets, measuring less than 5 microns, which can remain airborne for extended periods. The nurse should place a client with TB under airborne precautions to prevent the transmission of the disease. Choice A, contact precautions, are used for diseases that spread by direct or indirect contact. Choice C, droplet precautions, are for diseases transmitted by large droplets. Choice D, protective environment, is used for clients who have compromised immune systems.

4. When assessing a client with a small bowel obstruction, what finding should a nurse expect?

• A. Significant abdominal distention
• B. Large bowel movements
• C. High-pitched bowel sounds
• D. Copious vomiting

Correct answer: C

Rationale: High-pitched bowel sounds are often heard early in a small bowel obstruction due to increased peristalsis as the bowel tries to overcome the blockage. Choices A, B, and D are incorrect. Abdominal distention is more commonly associated with large bowel obstructions, while large bowel movements and copious vomiting are not typical findings in small bowel obstructions.

5. A nurse is assessing a client with a history of heart failure. Which of the following findings should the nurse monitor?

• A. Increased energy
• B. Peripheral edema
• C. Elevated heart rate
• D. Improved lung sounds

Correct answer: B

Rationale: The correct answer is B: Peripheral edema. In heart failure, the heart's inability to pump effectively can lead to fluid backup, causing swelling in the extremities, known as peripheral edema. Monitoring for peripheral edema is crucial as it is a common sign of worsening heart failure. Choices A, C, and D are incorrect because increased energy, elevated heart rate, and improved lung sounds are not typical findings in heart failure. Increased energy is not usually associated with heart failure, an elevated heart rate may occur as a compensatory mechanism but is not a direct sign of heart failure, and improved lung sounds are not expected in heart failure which often presents with crackles or wheezes due to pulmonary congestion.

Similar Questions