Nursing Elites

1. A healthcare professional is reviewing the laboratory values of a client who has respiratory acidosis. Which of the following findings should the healthcare professional expect?

• A. HCO3- 30 mEq/L
• B. PaCO2 50 mm Hg
• C. pH 7.45
• D. Potassium 3.3 mEq/L

Correct answer: B

Rationale: In respiratory acidosis, the primary disturbance is an increase in PaCO2 levels above the normal range of 35-45 mm Hg. Option B, PaCO2 50 mm Hg, indicates an elevated partial pressure of carbon dioxide, which is consistent with respiratory acidosis. Options A, C, and D are not directly indicative of respiratory acidosis. HCO3- (Option A) is more related to metabolic acidosis or alkalosis, pH (Option C) is within the normal range indicating no acid-base imbalance, and potassium (Option D) levels are not specific to respiratory acidosis.

2. 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.

3. A client at 10 weeks of gestation reports abdominal pain and moderate vaginal bleeding. The tentative diagnosis is inevitable abortion. Which of the following nursing interventions should be included in the plan of care?

• A. Administer oxygen via nasal cannula
• B. Offer option to view products of conception
• C. Instruct the client to increase potassium-rich foods in the diet
• D. Maintain the client on bed rest

Correct answer: B

Rationale: Offering the client the option to view products of conception after an inevitable abortion can provide closure and support the grieving process. It allows the client to have a visual confirmation of the pregnancy loss, which can aid in emotional healing. Administering oxygen is not a priority in this scenario as there is no indication of respiratory distress. Instructing the client to increase potassium-rich foods is not directly related to managing an inevitable abortion. Bed rest may be recommended, but offering the option to view products of conception is a more appropriate intervention at this time.

4. A client in labor at 40 weeks of gestation has saturated two perineal pads in the past 30 min. The nurse suspects placenta previa. Which of the following is an appropriate nursing action?

• A. Examination to determine cervical status
• B. A magnesium sulfate infusion
• C. Initiation of pushing
• D. Preparation for cesarean birth

Correct answer: D

Rationale: In the scenario described, the client is experiencing heavy vaginal bleeding, which is concerning for placenta previa. The appropriate nursing action in this situation is to prepare for a cesarean birth. Placenta previa is a condition where the placenta partially or completely covers the cervix, which can lead to life-threatening bleeding during labor. It is crucial to avoid vaginal examinations or initiation of pushing as these actions can exacerbate bleeding. A magnesium sulfate infusion is not indicated in the management of placenta previa. Therefore, the priority intervention is to prepare for a cesarean birth to ensure the safety of the mother and the baby.

5. A client who is 4 hours postpartum following a vaginal delivery is being assessed by a nurse. Which of the following findings should the nurse identify as the priority?

• A. Saturated perineal pad in 30 minutes
• B. Deep tendon reflexes 4+
• C. Fundus at the level of the umbilicus
• D. Approximated edges of episiotomy

Correct answer: A

Rationale: In a client who is 4 hours postpartum, a saturated perineal pad within 30 minutes is a priority finding as it may indicate excessive postpartum bleeding (hemorrhage), which requires immediate intervention to prevent further complications such as hypovolemic shock. Deep tendon reflexes being 4+ is within normal limits postpartum. The fundus at the level of the umbilicus is an expected finding at this time frame, indicating proper involution of the uterus. Approximated edges of an episiotomy suggest proper healing.

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