Nursing Elites

1. Jane Love, a 35-year-old gravida III para II at 23 weeks gestation, is seen in the Emergency Department with painless, bright red vaginal bleeding. Jane reports that she has been feeling tired and has noticed ankle swelling in the evening. Laboratory tests reveal a hemoglobin level of 11.5 g/dL. After evaluating the situation, the nurse determines that Jane is at risk for placenta previa, based on which of the following data?

• A. anemia
• B. edema
• C. painless vaginal bleeding
• D. fatigue

Correct answer: C

Rationale: Placenta previa is a disorder where the placenta implants in the lower uterine segment, causing painless bleeding in the third trimester of pregnancy. The bleeding results from tearing of the placental villi from the uterine wall as the lower uterine segment contracts and dilates. It can be slight or profuse and can include bright red, painless bleeding. While anemia (choice A) may be a consequence of chronic bleeding from placenta previa, it is not a direct indicator. Edema (choice B) and fatigue (choice D) are nonspecific symptoms that can occur in pregnancy but are not specific to placenta previa.

2. Clomiphene is prescribed for a female client to treat infertility. The nurse is providing information to the client and her spouse about the medication and provides the couple with which information?

• A. If the oral tablets are not successful, the medication will be administered intravenously.
• B. The couple should engage in coitus at least every other day during treatment.
• C. The physician should be notified immediately if breast engorgement occurs.
• D. Multiple births occur in a small percentage of clomiphene-facilitated pregnancies.

Correct answer: D

Rationale: The correct answer is that multiple births (usually twins) occur in a small percentage (8% - 10%) of clomiphene-facilitated pregnancies. The couple should be informed about this potential outcome. Clomiphene is available in 50-mg tablets for oral use; there is no intravenous form of the medication. Breast engorgement is a common side effect of clomiphene that typically resolves after discontinuation of the medication. Ovulation usually happens 5 to 10 days after the last dose of clomiphene, and the couple is advised to engage in coitus at least every other day during this time. Therefore, choices A, B, and C are incorrect as they do not provide accurate information regarding clomiphene treatment for infertility.

3. A nurse is working in a pediatric clinic, and a 25-year-old mother comes in with a 4-week-old baby. The mother is stressed out about the loss of sleep, and the baby exhibits signs of colic. Which of the following techniques should the nurse teach the mother?

• A. Distraction of the infant with a red object
• B. Prone positioning techniques
• C. Tapping reflex techniques
• D. Neural warmth techniques

Correct answer: D

Rationale: Neural warmth techniques involve the caregiver providing a warm, soothing touch to the baby, which can help to lower the baby's agitation level and promote relaxation. This technique is beneficial for calming colicky babies. Choices A, B, and C are incorrect because distraction with a red object, prone positioning, and tapping reflex techniques are not effective methods for managing colic in infants. Red object distraction is not a proven technique for soothing colicky babies. Prone positioning is not recommended for infants due to the risk of sudden infant death syndrome (SIDS). Tapping reflex techniques are not recognized as effective interventions for colic.

4. A homeless person has been admitted to the medical unit and placed on airborne precautions for suspected active TB infection. The nurse will assess for these signs and symptoms (Select one that doesn't apply).

• A. Weight gain
• B. Fatigue
• C. Bloody sputum
• D. Diaphoresis during sleep

Correct answer: A

Rationale: The correct answer is 'Weight gain.' When assessing for signs and symptoms of active TB infection, weight loss is typically observed rather than weight gain. Other common signs and symptoms include fatigue, bloody sputum, and diaphoresis during sleep. Fatigue, bloody sputum, and diaphoresis during sleep are all associated with active TB infection. Weight gain is not typically seen in active TB; instead, patients usually experience weight loss due to the impact of the infection on their overall health.

5. When treating anemia in clients with renal failure, erythropoietin should be given in conjunction with:

• A. iron, folic acid, and B12.
• B. an increase in protein in the diet.
• C. vitamins A and C.
• D. an increase in calcium in the diet.

Correct answer: A

Rationale: Erythropoietin is used to stimulate red blood cell production in clients with renal failure. To effectively increase red blood cell production, adequate levels of iron, folic acid, and B12 are necessary. These nutrients play crucial roles in erythropoiesis. Choices B, an increase in protein in the diet, is not directly related to enhanced erythropoiesis and can potentially worsen uremia. Choices C and D, vitamins A and C, and an increase in calcium in the diet, are not directly involved in red blood cell production and are not essential in this context.

Similar Questions