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 receiving heparin. Which of the following should the nurse monitor?

• A. INR levels
• B. APTT levels
• C. Blood glucose levels
• D. Liver function tests

Correct answer: B

Rationale: Heparin therapy requires monitoring of activated partial thromboplastin time (APTT) to ensure therapeutic levels. APTT reflects the intrinsic pathway of the clotting cascade and is used to assess the effectiveness and safety of heparin therapy. Monitoring INR levels is more relevant for assessing warfarin therapy, not heparin. Blood glucose levels are monitored for clients with diabetes or those on medications affecting glucose levels. Liver function tests are used to assess liver health and are not directly related to monitoring heparin therapy.

3. A client with a new diagnosis of heart failure is prescribed furosemide. Which of the following instructions should the nurse include?

• A. Take the medication in the morning.
• B. Increase intake of potassium-rich foods.
• C. Report a decrease in urine output.
• D. Expect swelling in the lower extremities.

Correct answer: B

Rationale: The correct answer is to instruct the client to increase their intake of potassium-rich foods. Furosemide, a loop diuretic, can lead to potassium loss, which may cause hypokalemia. Increasing potassium intake can help prevent this electrolyte imbalance. Choice A is incorrect because furosemide is usually taken in the morning to prevent sleep disturbances due to increased urination. Choice C is incorrect because a decrease in urine output could indicate a problem and should be reported immediately. Choice D is incorrect because furosemide is used to reduce swelling in the body, including the lower extremities, so expecting swelling is not appropriate.

4. A client with a history of asthma is being cared for by a nurse. Which of the following should the nurse monitor?

• A. Heart rate
• B. Respiratory status
• C. Blood glucose levels
• D. Liver function

Correct answer: B

Rationale: The correct answer is B: Respiratory status. When caring for a client with asthma, it is essential to monitor their respiratory status to detect any changes in breathing or signs of airway obstruction. Monitoring heart rate (choice A) may be important in some situations but is not the priority when managing asthma. Blood glucose levels (choice C) and liver function (choice D) are not directly related to asthma and would not be the primary focus of monitoring for a client with this condition.

5. A client is being treated with thiazide diuretics. What should the nurse monitor regularly?

• A. Hyperkalemia
• B. Hypokalemia
• C. Hyponatremia
• D. Hypoglycemia

Correct answer: B

Rationale: Thiazide diuretics are known to cause hypokalemia by increasing potassium excretion in the urine. Therefore, the nurse should monitor the client for low potassium levels. Hyperkalemia (Choice A) is not typically associated with thiazide diuretics. Hyponatremia (Choice C) is more commonly linked with thiazide diuretics due to increased sodium excretion. Hypoglycemia (Choice D) is not a usual concern when a client is receiving thiazide diuretics.

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