Nursing Elites

1. A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate via IV infusion. Which of the following findings indicates magnesium toxicity?

• A. Blood glucose of 150 mg/dL
• B. Urine output of 20 mL/hour
• C. Systolic blood pressure of 140 mm Hg
• D. BUN 20 mg/dL

Correct answer: B

Rationale: The correct answer is B. A urine output of 20 mL/hour is a sign of magnesium toxicity because decreased urine output can lead to accumulation of magnesium. Choices A, C, and D are not indicators of magnesium toxicity. Elevated blood glucose, high systolic blood pressure, and normal BUN levels do not specifically point towards magnesium toxicity.

2. A nurse is providing discharge teaching to a client who has a prescription for home oxygen. Which information should the nurse teach?

• A. Use a humidifier with the oxygen
• B. Wear cotton socks when the oxygen is in use
• C. Avoid all types of smoking materials
• D. Use a nasal cannula during meals

Correct answer: B

Rationale: The correct answer is B: 'Wear cotton socks when the oxygen is in use.' This information is important as wearing cotton socks helps prevent static electricity, which can pose a fire risk when oxygen is in use. Choice A is incorrect as using a humidifier with oxygen is not necessary for all clients and may not be part of standard discharge teaching. Choice C is incorrect as it is a common safety measure to avoid all types of smoking materials when using oxygen. Choice D is incorrect as using a nasal cannula during meals is not specifically related to the safety concerns associated with home oxygen use.

3. A charge nurse is planning care for a group of patients on a med-surg unit. What task should the nurse delegate to an assistive personnel?

• A. Measure hourly urinary output for the postoperative patient.
• B. Administer medications to stable patients.
• C. Reinforce patient education.
• D. Initiate a care plan for a new patient.

Correct answer: A

Rationale: The correct answer is A because assistive personnel can be assigned to measure and document urinary output, a routine task within their scope of practice. Administering medications (choice B) requires a higher level of training and should be done by licensed nurses. Reinforcing patient education (choice C) involves providing information and ensuring patient understanding, which is typically done by licensed healthcare providers. Initiating a care plan (choice D) involves critical thinking and assessment skills, which are beyond the scope of practice for assistive personnel.

4. A nurse is caring for a laboring client and notes that the fetal heart rate begins to decelerate after the contraction has started. The lowest point of deceleration occurs after the peak of the contraction. What is the priority nursing action?

• A. Administer oxygen
• B. Change the client's position
• C. Increase IV fluids
• D. Call the healthcare provider

Correct answer: B

Rationale: Late decelerations are caused by uteroplacental insufficiency, indicating that the fetus is not receiving adequate oxygen during contractions. This is an emergency that requires prompt intervention. Changing the client's position helps improve placental blood flow, reducing stress on the fetus. Administering oxygen may be necessary if changing position does not resolve the decelerations. Increasing IV fluids is not the priority in this situation as it won't directly address the cause of late decelerations. Calling the healthcare provider should be done after immediate interventions like changing the client's position have been implemented and assessed.

5. A nurse is caring for a client who is postpartum, has a deep-vein thrombosis, and is receiving heparin therapy via subcutaneous injections. Which of the following actions should the nurse take?

• A. Request a prescription for PRN aspirin from the provider.
• B. Massage the injection site thoroughly following administration.
• C. Instruct the client that they cannot breastfeed while receiving heparin.
• D. Administer the injection in the client's abdomen.

Correct answer: D

Rationale: The nurse should administer the injection in the abdomen, as this is a common site for subcutaneous heparin administration. Massaging the injection site can lead to bruising or discomfort and should be avoided. Instructing the client not to breastfeed while on heparin is inaccurate, as heparin does not pass into breast milk in significant amounts. Aspirin is contraindicated for clients on heparin due to the increased risk of bleeding, so requesting a prescription for PRN aspirin would not be appropriate in this situation.

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