Nursing Elites

1. A client who is 28 weeks pregnant and has preeclampsia is being cared for by a nurse. Which of the following is the priority assessment?

• A. Level of consciousness
• B. Deep tendon reflexes
• C. Blood pressure
• D. Urinary output

Correct answer: C

Rationale: Blood pressure is the priority assessment in clients with preeclampsia because hypertension is the primary symptom of the condition. Elevated blood pressure increases the risk of complications such as eclampsia and placental abruption. Assessing the blood pressure helps in monitoring the severity of the preeclampsia and guiding appropriate interventions. While monitoring the client's level of consciousness, deep tendon reflexes, and urinary output are important, they are secondary assessments in the context of preeclampsia.

2. A client presents with symptoms suggestive of rheumatoid arthritis. Which of the following laboratory tests should be ordered to confirm this diagnosis?

• A. Erythrocyte sedimentation rate (ESR)
• B. Rheumatoid factor
• C. Antinuclear antibody
• D. Serum calcium

Correct answer: B

Rationale: Rheumatoid factor is a specific marker for rheumatoid arthritis. It is often elevated in clients with this autoimmune condition, helping to confirm the diagnosis. Erythrocyte sedimentation rate (ESR) and antinuclear antibody tests can be supportive but are not specific for rheumatoid arthritis. Serum calcium levels are not typically used to confirm this diagnosis.

3. A nurse is preparing to administer regular insulin and NPH insulin. What is the proper sequence of events the nurse should follow?

• A. Inspect the vials for contamination.
• B. Withdraw regular insulin first, then NPH.
• C. Inject air into the NPH insulin vial first.
• D. Roll the NPH insulin vial between the hands to mix.

Correct answer: A

Rationale: The correct sequence of events for administering regular insulin and NPH insulin begins with inspecting the vials for contamination to ensure patient safety. Rolling the NPH insulin vial between the hands to mix and injecting air into the NPH insulin vial should follow the inspection step. Afterward, the nurse should inject air into the regular insulin vial and then withdraw the regular insulin first. Option A is the correct answer as it outlines the initial crucial step in the administration process. Option B is incorrect as it provides the incorrect order of withdrawing the insulins. Option C is incorrect as injecting air into the NPH insulin vial should come after inspecting the vials. Option D is incorrect as rolling the NPH insulin vial should be done after inspecting the vials and injecting air into the NPH insulin vial.

4. A patient scheduled for cataract surgery tells the nurse, 'I see just fine and have decided to cancel my surgery.' Which response should the nurse make?

• A. Tell the patient they need the surgery
• B. Encourage the patient to express their thoughts
• C. Ignore the comment and proceed
• D. Insist the patient needs to proceed with the surgery

Correct answer: B

Rationale: Encouraging the patient to express their thoughts is the best response in this situation. It allows the patient to voice their concerns or reasons for canceling the surgery, which can help the healthcare team address any misunderstandings or fears the patient may have. Choices A and D are too directive and do not consider the patient's autonomy and right to make informed decisions about their care. Choice C is inappropriate as it disregards the patient's expressed decision and fails to address the underlying issue.

5. A nurse is caring for a client receiving heparin. Which of the following should the nurse monitor?

• A. INR levels
• B. APTT levels
• C. Blood glucose levels
• D. Liver function tests

Correct answer: B

Rationale: Heparin therapy requires monitoring of activated partial thromboplastin time (APTT) to ensure therapeutic levels. APTT reflects the intrinsic pathway of the clotting cascade and is used to assess the effectiveness and safety of heparin therapy. Monitoring INR levels is more relevant for assessing warfarin therapy, not heparin. Blood glucose levels are monitored for clients with diabetes or those on medications affecting glucose levels. Liver function tests are used to assess liver health and are not directly related to monitoring heparin therapy.

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