Nursing Elites

1. A nurse is planning to administer diltiazem via IV bolus to a client who has atrial fibrillation. Which of the following findings is a contraindication to the administration of diltiazem?

• A. Hypotension
• B. Tachycardia
• C. Decreased level of consciousness
• D. History of diuretic use

Correct answer: A

Rationale: The correct answer is A: Hypotension. Diltiazem, a calcium channel blocker, can cause hypotension. Administering diltiazem to a client with hypotension can further lower their blood pressure, leading to adverse effects like dizziness and syncope. Tachycardia (Choice B) is actually a common indication for diltiazem use, as it helps slow down the heart rate in conditions like atrial fibrillation. Decreased level of consciousness (Choice C) may require evaluation but is not a direct contraindication to diltiazem administration. History of diuretic use (Choice D) is not a contraindication to diltiazem, as the two medications can often be safely used together.

2. A nurse is providing teaching to a client who is at 34 weeks of gestation and is scheduled for a nonstress test. Which of the following statements should the nurse plan to make?

• A. You will not receive medication through an IV for this test.
• B. You should expect the test to take about 30 minutes.
• C. You do not need to eat or drink for 4 hours prior to the test.
• D. This test will help determine if your baby's lungs are mature.

Correct answer: B

Rationale: The correct statement for the nurse to make is choice B, 'You should expect the test to take about 30 minutes.' The nonstress test is used to assess fetal well-being by monitoring fetal heart rate in response to movements. Choice A is incorrect because medications are not typically administered during a nonstress test. Choice C is incorrect as there is no need for the client to fast before the test. Choice D is incorrect because determining fetal lung maturity is usually done through other tests, not the nonstress test.

3. 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.

4. A nurse is assessing a client 2 hours after a vaginal delivery and notes that the client's uterus is boggy and displaced to the right. Which of the following interventions should the nurse perform first?

• A. Assist the client to void
• B. Massage the uterus
• C. Administer oxytocin
• D. Encourage breastfeeding

Correct answer: A

Rationale: A boggy and displaced uterus is often a sign of bladder distention, which can prevent the uterus from contracting effectively. The priority intervention is to assist the client to void. By emptying the bladder, the uterus can return to midline and become firm. Massaging the uterus or administering oxytocin may be necessary but should come after addressing the bladder distention. Encouraging breastfeeding is important for uterine contraction but is not the priority in this situation.

5. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following assessment findings requires immediate intervention by the nurse?

• A. Prealbumin level of 20 mg/dL
• B. Weight increase of 2 kg/day
• C. Temperature of 37.6°C
• D. Blood glucose level of 120 mg/dL

Correct answer: B

Rationale: A rapid weight gain of 2 kg/day suggests fluid overload, a possible complication of TPN. This requires immediate intervention to prevent further complications such as pulmonary edema. The other options are not indicative of immediate complications related to TPN. A low prealbumin level may indicate malnutrition but does not require immediate intervention. A slightly elevated temperature and blood glucose level are within normal ranges and do not warrant immediate action.

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