Nursing Elites

1. A postpartum client's fundus is firm, 3 cm above the umbilicus, and displaced to the right. Which of the following interventions should the nurse take?

• A. Massage the fundus
• B. Administer oxytocin
• C. Assist the client to void then reassess the fundus
• D. Notify the healthcare provider

Correct answer: C

Rationale: The correct intervention for a postpartum client with a firm, displaced fundus is to assist the client to void then reassess the fundus. Displacement of the uterus to the right is often a sign of bladder distention, which can prevent the uterus from contracting properly and increase the risk of postpartum hemorrhage. By helping the client to void, the nurse can alleviate the bladder distention, allowing the uterus to contract effectively. Massaging the fundus (Choice A) may not address the underlying issue of bladder distention. Administering oxytocin (Choice B) is not indicated without assessing and addressing the cause of the displacement. Notifying the healthcare provider (Choice D) is premature before implementing initial nursing interventions to address the potential cause of the displaced fundus.

2. A nurse is caring for a client prescribed clopidogrel. Which of the following should the nurse monitor?

• A. Liver function tests
• B. Blood pressure
• C. Potassium levels
• D. Respiratory rate

Correct answer: A

Rationale: Corrected Rationale: Clopidogrel is an antiplatelet medication, so the nurse should monitor for signs of bleeding and liver function tests due to potential liver effects. Monitoring liver function tests is essential to detect any adverse effects on the liver because clopidogrel can cause hepatotoxicity. While monitoring blood pressure, potassium levels, and respiratory rate are important in general patient care, they are not the priority assessments specifically related to clopidogrel use.

3. A nurse is caring for a client with a new prescription for clindamycin. Which of the following should the nurse monitor?

• A. Liver function
• B. Serum potassium
• C. Signs of superinfection
• D. Blood glucose

Correct answer: C

Rationale: The correct answer is C: Signs of superinfection. Clindamycin can lead to antibiotic-associated colitis and other superinfections, making it crucial for the nurse to monitor the client for signs of superinfection. Monitoring liver function (choice A) is not typically associated with clindamycin use. Serum potassium levels (choice B) and blood glucose (choice D) are also not directly affected by clindamycin, so they are not the priority for monitoring in this case.

4. A nurse is caring for a client who is receiving IV diltiazem for 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 can cause further lowering of blood pressure, so it should not be administered if the client is already hypotensive. Monitoring blood pressure is crucial before giving diltiazem. Choice B, tachycardia, is not a contraindication for diltiazem use; in fact, diltiazem is used to slow down the heart rate. Choice C, decreased level of consciousness, may indicate other issues but is not a direct contraindication for diltiazem. Choice D, history of diuretic use, is not a contraindication by itself; however, caution should be exercised when diltiazem is given with diuretics due to potential interactions.

5. A nurse is caring for a client in preterm labor who is receiving magnesium sulfate. Which of the following is an indication of magnesium toxicity?

• A. Blood glucose of 160 mg/dL
• B. Urine output of 20 mL/hour
• C. Systolic BP of 140 mm Hg
• D. Respiratory rate of 20/min

Correct answer: B

Rationale: The correct answer is B: Urine output of 20 mL/hour. Urine output below 30 mL/hour is a sign of magnesium toxicity due to the risk of accumulation in the body. Choices A, C, and D are not indicative of magnesium toxicity. Elevated blood glucose, systolic blood pressure, and normal respiratory rate are not specific signs of magnesium toxicity.

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