Nursing Elites

1. A nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which of the following findings should the nurse report to the healthcare provider?

• A. Urinary output of 40 mL/hr
• B. Respiratory rate of 10 breaths per minute
• C. Absent deep tendon reflexes
• D. Blood pressure of 150/90 mm Hg

Correct answer: B

Rationale: Magnesium sulfate can depress the central nervous system, leading to respiratory depression. A respiratory rate of 10 breaths per minute is below the normal range and requires immediate intervention. Urinary output of 40 mL/hr (Choice A) is within the normal range for a client receiving magnesium sulfate. Absent deep tendon reflexes (Choice C) are an expected finding due to the medication's effect on neuromuscular excitability. A blood pressure of 150/90 mm Hg (Choice D) is slightly elevated but not a priority concern compared to severe respiratory depression.

2. A nurse is preparing to administer a dose of losartan. Which of the following should the nurse assess first?

• A. Blood pressure
• B. Heart rate
• C. Serum potassium
• D. Liver function

Correct answer: A

Rationale: The correct answer is to assess blood pressure first. Losartan is an angiotensin receptor blocker used to lower blood pressure. Assessing the patient's blood pressure before administering losartan is crucial to ensure it is not already too low, which could lead to hypotension. Assessing heart rate (choice B) is important but not the priority when administering losartan. Serum potassium levels (choice C) and liver function (choice D) are also important assessments, but they are not the primary concern before administering losartan.

3. A client receiving opiates for pain management was initially sedated but is no longer sedated after three days. What action should the nurse take?

• A. Initiate additional non-pharmacological pain management techniques.
• B. Notify the provider that a dosage adjustment is needed.
• C. No action is needed at this time.
• D. Contact the provider to request an alternate method of pain management.

Correct answer: C

Rationale: The correct answer is C: No action is needed at this time. Sedation from opiates commonly decreases as the body adjusts to the medication. It is a positive sign that the sedation has resolved, indicating the client is tolerating the current dosage well. Initiating additional non-pharmacological pain management techniques (Choice A) is unnecessary since the current pain management regimen is effective. Notifying the provider for a dosage adjustment (Choice B) is premature and not indicated when the sedation has resolved. Contacting the provider to request an alternate method of pain management (Choice D) is excessive and not warranted in this situation where the client is no longer sedated and the current pain management plan is effective.

4. A nurse is completing an assessment of a newborn who is 2 hours old. Which of the following findings is indicative of cold stress?

• A. Respiratory rate of 60 per minute
• B. Jitteriness of the hands
• C. Diaphoresis
• D. Bounding peripheral pulses

Correct answer: B

Rationale: Jitteriness of the hands is a classic sign of cold stress in newborns, indicating that the infant is having difficulty maintaining a stable body temperature. Cold stress can lead to hypoglycemia and increased oxygen consumption. The other options (A, C, and D) are not directly associated with cold stress in newborns. A respiratory rate of 60 per minute may be within the normal range for a newborn. Diaphoresis (excessive sweating) and bounding peripheral pulses are not specific signs of cold stress in newborns.

5. While assessing four clients, which client data should be reported to the provider?

• A. Client with pleurisy who reports a pain level of 6 out of 10 when coughing
• B. Client with 110 mL of serosanguineous fluid from a JP drain
• C. Client 4 hours postoperative with a heart rate of 98 bpm
• D. Client undergoing chemotherapy with an absolute neutrophil count of 75/mm³

Correct answer: D

Rationale: An absolute neutrophil count of 75/mm³ is critically low and places the client at high risk for infection, necessitating immediate intervention. Neutropenia increases susceptibility to infections, making it essential to report this finding promptly. The other options, such as pain level in pleurisy, drainage amount from a drain, and heart rate postoperatively, are important but do not indicate an immediate life-threatening condition that requires urgent provider notification.

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