Nursing Elites

1. A client who is 2 hours postpartum following a cesarean birth has a history of thromboembolic disease. Which of the following nursing interventions should be included in the plan of care?

• A. Apply warm, moist heat to the client's lower extremities.
• B. Massage the client's posterior lower legs.
• C. Place pillows under the client's knees when resting in bed.
• D. Have the client ambulate.

Correct answer: D

Rationale: The correct intervention for a client who is 2 hours postpartum following a cesarean birth with a history of thromboembolic disease is to have the client ambulate. Early ambulation is crucial in preventing complications such as deep vein thrombosis in postpartum clients. Applying warm, moist heat, massaging the legs, or placing pillows under the knees do not directly address the risk of thromboembolic disease in this scenario.

2. When caring for a newborn with macrosomia born to a mother with diabetes mellitus, which newborn complication should the nurse prioritize care for?

• A. Hypoglycemia
• B. Hypomagnesemia
• C. Hyperbilirubinemia
• D. Hypocalcemia

Correct answer: A

Rationale: In newborns of diabetic mothers with macrosomia, hypoglycemia is the priority focus of care due to the risk of developing low blood sugar levels after birth. Infants born to diabetic mothers are at risk of hypoglycemia because they have been exposed to high glucose levels in utero and produce high levels of insulin. Hypoglycemia can lead to serious complications if not promptly identified and managed, making it crucial for nurses to closely monitor blood glucose levels and provide necessary interventions to prevent adverse outcomes.

3. During an assessment, a nurse is evaluating a pregnant client for preeclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder?

• A. Increased urine output
• B. Vaginal discharge
• C. Elevated blood pressure
• D. Joint pain

Correct answer: C

Rationale: Preeclampsia is characterized by elevated blood pressure, proteinuria, and sometimes edema. Hypertension is a key sign of preeclampsia, and if present, further evaluation and monitoring are necessary to prevent complications for both the mother and the fetus.

4. When reviewing the arterial blood gas values for a client, a nurse notes a pH of 7.32, PaCO2 of 48 mm Hg, and HCO3 of 23 mEq/L. What does this indicate about the acid-base balance?

• A. Respiratory acidosis
• B. Respiratory alkalosis
• C. Metabolic acidosis
• D. Metabolic alkalosis

Correct answer: A

Rationale: The given values suggest respiratory acidosis. In respiratory acidosis, the pH is low (<7.35), PaCO2 is high (>45 mm Hg), and the HCO3 is normal or slightly elevated. In this scenario, the low pH (7.32) and high PaCO2 (48 mm Hg) indicate respiratory acidosis, where there is an excess of carbon dioxide in the blood, leading to acidification of the body fluids.

5. A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22, PaCO2 68 mm Hg, Base excess -2, PaO2 78 mm Hg, Saturation 80%, Bicarbonate 26 mEq/L

• A. Respiratory acidosis
• B. Metabolic acidosis
• C. Metabolic alkalosis
• D. Respiratory alkalosis

Correct answer: A

Rationale: The ABG values provided indicate respiratory acidosis. In respiratory acidosis, there is an increase in PaCO2 above the normal range (35-45 mm Hg) leading to a decrease in pH (<7.35). In this case, the pH is 7.22 (below normal) with an elevated PaCO2 of 68 mm Hg. The other values do not suggest metabolic acidosis (which would typically show low bicarbonate levels) or metabolic alkalosis. Therefore, the correct interpretation of the ABGs is respiratory acidosis.

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