Nursing Elites

1. A client is 4 hours postpartum. Which of the following interventions should be implemented to prevent postpartum hemorrhage?

• A. Monitor for signs of infection.
• B. Massage the uterus every 4 hours.
• C. Apply ice packs to the perineum.
• D. Administer methylergonovine IM.

Correct answer: D

Rationale: Administering methylergonovine intramuscularly helps contract the uterus, reducing the risk of postpartum hemorrhage. Monitoring for signs of infection (Choice A) is important but not directly related to preventing postpartum hemorrhage. Uterine massage (Choice B) is beneficial to prevent uterine atony, but methylergonovine is a more specific intervention to prevent hemorrhage. Applying ice packs to the perineum (Choice C) is helpful for perineal pain and swelling, not for preventing postpartum hemorrhage.

2. A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings should the nurse report to the provider?

• A. Serum calcium level of 8 mg/dL.
• B. Urine output of 60 mL/hr.
• C. Heart rate of 110/min.
• D. Temperature of 37.5°C (99.5°F).

Correct answer: C

Rationale: The correct answer is C. A heart rate of 110/min is elevated and may indicate hypocalcemia, a potential complication following a thyroidectomy. Elevated heart rate can be a sign of hypocalcemia due to the close relationship between calcium levels and cardiac function. Option A, serum calcium level of 8 mg/dL, is within the normal range (8.5-10.5 mg/dL) and would not be a cause for concern post-thyroidectomy. Option B, urine output of 60 mL/hr, is within the normal range for urine output and not typically a priority finding post-thyroidectomy. Option D, a temperature of 37.5°C (99.5°F), is slightly elevated but not a critical finding post-thyroidectomy unless accompanied by other symptoms.

3. A nurse is caring for a client who is 1 hour postpartum. Which of the following findings should the nurse report to the provider?

• A. Fundus firm and at the umbilicus.
• B. Heart rate 80/min.
• C. Blood pressure 130/78 mm Hg.
• D. A constant trickle of bright red blood from the vagina.

Correct answer: D

Rationale: After childbirth, it is normal for the fundus to be firm and at the level of the umbilicus, heart rate to be around 80/min, and blood pressure to be slightly elevated. However, a constant trickle of bright red blood from the vagina is concerning as it could indicate postpartum hemorrhage. This finding should be reported promptly to the healthcare provider for further evaluation and intervention. Choices A, B, and C are within expected postpartum parameters and do not indicate an immediate need for intervention.

4. A client is prescribed albuterol. Which of the following instructions should the nurse include?

• A. Take this medication before meals.
• B. You might experience tremors while taking this medication.
• C. Limit your caffeine intake while taking this medication.
• D. Take this medication at bedtime.

Correct answer: B

Rationale: The correct answer is B. Albuterol can cause tremors as a common side effect. Instructing the client about this potential side effect is crucial for their awareness and preparedness. Choices A, C, and D are incorrect because taking albuterol before meals, limiting caffeine intake, or taking it at bedtime are not specific instructions related to managing the side effects of albuterol like tremors.

5. A nurse is caring for a client who is 1 day postoperative following abdominal surgery. The nurse should suspect that the client has developed an infection based on which of the following findings?

• A. Blood pressure of 110/70 mm Hg
• B. Temperature of 38.5°C (101.3°F)
• C. Heart rate of 92/min
• D. Drainage at the surgical site

Correct answer: B

Rationale: An elevated temperature of 38.5°C (101.3°F) is indicative of infection postoperatively. Fever is a common sign of infection, and temperatures above the normal range should raise suspicion. The other vital signs (blood pressure, heart rate) may be within an acceptable range, and some drainage at the surgical site can be expected postoperatively. However, the elevated temperature is a more specific indicator of a potential infection that requires immediate attention.

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