Nursing Elites

1. A nurse is reviewing a laboratory report for a client who is at 33 weeks of gestation and has preeclampsia. Which of the following laboratory results should the nurse report to the provider?

• A. BUN 35 mg/dL
• B. Hgb 15 g/dL
• C. Bilirubin 0.6 mg/dL
• D. Hct 37%

Correct answer: A

Rationale: A BUN of 35 mg/dL indicates potential kidney impairment, which is a concern in preeclampsia due to compromised renal function. This finding warrants further evaluation by the provider. High BUN levels may suggest reduced kidney function, a common complication associated with preeclampsia. Hgb, Bilirubin, and Hct levels are within normal ranges and are not directly indicative of kidney impairment or preeclampsia in this scenario. Therefore, the nurse should report the elevated BUN level to the healthcare provider for prompt management and monitoring.

2. A nurse is assessing a client 1 hour after birth and notes a boggy uterus located 2 cm above the umbilicus. What should the nurse do first?

• A. Take vital signs
• B. Assess lochia
• C. Massage the fundus
• D. Give oxytocin IV bolus

Correct answer: C

Rationale: A boggy uterus located 2 cm above the umbilicus suggests uterine atony, which is a common cause of postpartum hemorrhage. The initial intervention in this situation is to massage the fundus. Fundal massage helps the uterus contract, promoting hemostasis and preventing excessive bleeding. Taking vital signs or assessing lochia are important actions but are secondary to addressing uterine atony. Administering oxytocin IV bolus is often done after fundal massage to further enhance uterine contractions.

3. A nurse is assessing a client who is 24 hours postpartum. Which of the following findings should the nurse report to the healthcare provider?

• A. Uterine fundus is firm and midline
• B. Client's perineal pad is saturated in 15 minutes
• C. Client reports breast tenderness when breastfeeding
• D. Client's temperature is 100.4°F

Correct answer: B

Rationale: A perineal pad saturated in 15 minutes is a sign of excessive postpartum bleeding, which requires immediate medical attention to prevent postpartum hemorrhage. The other findings are normal postpartum occurrences. A firm and midline uterine fundus indicates proper involution, breast tenderness during breastfeeding is common due to engorgement, and a temperature of 100.4°F is considered within the normal range for the postpartum period.

4. A nurse is caring for a client who has been taking haloperidol for several years. Which of the following assessment findings should the nurse recognize as a long-term side effect of this medication?

• A. Lip-smacking
• B. Agranulocytosis
• C. Clang association
• D. Alopecia

Correct answer: A

Rationale: Lip-smacking is a symptom of tardive dyskinesia, a long-term side effect of antipsychotic medications like haloperidol, characterized by involuntary movements of the face and jaw. Agranulocytosis (Choice B) is a rare but serious side effect of some medications, characterized by a dangerously low white blood cell count. Clang association (Choice C) is a thought disorder characterized by the association of words based on sound rather than meaning. Alopecia (Choice D) refers to hair loss, which is not a known long-term side effect of haloperidol.

5. A nurse is preparing to insert an indwelling urinary catheter into a female client. Which of the following actions should the nurse take?

• A. Inflate the balloon with 10 mL of sterile water prior to insertion
• B. Cleanse the client’s labia and meatus using a front-to-back motion
• C. Ask the client to bear down while inserting the catheter
• D. Inflate the catheter balloon after urine begins to flow

Correct answer: D

Rationale: The correct action for the nurse to take when inserting an indwelling urinary catheter into a female client is to inflate the catheter balloon after urine begins to flow. Inflating the balloon before urine starts flowing can lead to incorrect placement in the urethra, causing trauma. Cleansing the labia and meatus should be done before the insertion, but the crucial step of inflating the balloon should occur after the catheter is correctly placed. Asking the client to bear down is not necessary during catheter insertion.

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