Nursing Elites

1. While assessing a client with preeclampsia who is receiving magnesium sulfate, the nurse notes her deep tendon reflexes are 1+, respiratory rate is 12 breaths/minute, urinary output is 90 ml in 4 hours, and magnesium sulfate level is 9 mg/dl. What intervention should the nurse implement based on these findings?

• A. Continue the magnesium sulfate infusion as prescribed.
• B. Decrease the magnesium sulfate infusion by one-half.
• C. Stop the magnesium sulfate infusion immediately.
• D. Administer calcium gluconate immediately.

Correct answer: C

Rationale: The nurse should stop the magnesium sulfate infusion immediately in a client with preeclampsia exhibiting diminished reflexes, respiratory depression, and low urinary output, which indicate magnesium sulfate toxicity. This action is crucial to prevent further complications and adverse effects on the client.

2. A 40-year-old man presents with abdominal pain, diarrhea, and weight loss. He has a history of Crohn's disease. Laboratory tests reveal low hemoglobin and elevated ESR. What is the most likely diagnosis?

• A. Ulcerative colitis
• B. Irritable bowel syndrome
• C. Celiac disease
• D. Crohn's disease flare

Correct answer: D

Rationale: The symptoms of abdominal pain, diarrhea, weight loss, along with the history of Crohn's disease, and the laboratory findings of low hemoglobin and elevated ESR, strongly suggest a Crohn's disease flare. These clinical manifestations are classic features of a flare-up in a patient with a known history of Crohn's disease.

3. A client with type 2 diabetes mellitus is prescribed metformin (Glucophage). Which instruction should the nurse provide?

• A. Take the medication on an empty stomach.
• B. Limit your fluid intake while on this medication.
• C. Monitor your blood glucose levels regularly.
• D. Avoid eating foods high in potassium.

Correct answer: C

Rationale: Monitoring blood glucose levels regularly is crucial for clients with type 2 diabetes who are taking metformin. This helps assess the effectiveness of the medication in managing blood sugar levels and allows for timely adjustments in the treatment plan if needed. By monitoring blood glucose levels, the client and healthcare team can work together to achieve optimal diabetes control and prevent complications associated with uncontrolled blood sugar levels.

4. A client with a history of peptic ulcer disease is admitted with severe abdominal pain. Which assessment finding should the nurse report to the healthcare provider immediately?

• A. Bowel sounds active in all quadrants.
• B. Blood pressure of 110/70 mm Hg.
• C. Rigid, board-like abdomen.
• D. Heart rate of 90 beats per minute.

Correct answer: C

Rationale: A rigid, board-like abdomen is a sign of peritonitis, a serious complication of peptic ulcer disease that can lead to sepsis and requires immediate intervention. This finding indicates a potential emergency situation that needs urgent medical attention to prevent further complications.

5. The community mental health nurse is planning to visit four clients with schizophrenia today. Which client should the nurse see first?

• A. The mother who took her children from school because aliens were after them.
• B. The young man who has a history of substance abuse and no telephone.
• C. The newly diagnosed client who needs to be evaluated for medication compliance.
• D. The young woman who believes she is to blame for her recent miscarriage.

Correct answer: A

Rationale: The mother who took her children from school due to delusions of aliens poses a significant risk to her children and herself. This situation requires immediate attention to ensure the safety and well-being of all involved. Choice B is concerning due to the history of substance abuse, but the immediate risk to life and safety as in Choice A takes precedence. Choice C, although important, does not present an immediate danger as the delusional belief of aliens. Choice D, while emotionally distressing, does not pose an immediate threat as the situation described in Choice A.

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