Nursing Elites

1. A 23-year-old woman at 32-weeks gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, would indicate a possible complication?

• A. The client's urine test is positive for glucose and acetone
• B. The client has 1+ pedal edema in both feet at the end of the day
• C. The client complains of an increase in vaginal discharge
• D. The client says she feels pressure against her diaphragm when the baby moves

Correct answer: A

Rationale: The correct answer is A. Positive urine glucose and acetone could indicate gestational diabetes or preeclampsia, both of which are complications. Choice B, pedal edema, is common in pregnancy but may also be a sign of preeclampsia if severe. Choice C, an increase in vaginal discharge, is a normal finding in pregnancy due to hormonal changes. Choice D, pressure against the diaphragm when the baby moves, is a normal sensation due to the growing uterus displacing abdominal contents.

2. A client with heart failure is receiving furosemide. Which of the following assessment findings indicates that the medication is effective?

• A. Elevated blood pressure.
• B. Absence of adventitious breath sounds.
• C. Weight gain of 1.4 kg (3 lb) in 24 hr.
• D. Decreased urine output.

Correct answer: B

Rationale: The absence of adventitious breath sounds indicates that furosemide is effective in managing heart failure. Adventitious breath sounds such as crackles indicate fluid accumulation in the lungs, a common complication of heart failure. Therefore, the absence of these abnormal sounds suggests that furosemide is effectively reducing fluid overload. Elevated blood pressure (choice A) is not a desired outcome in heart failure management. Weight gain (choice C) and decreased urine output (choice D) are signs of fluid retention and ineffective diuresis, indicating that furosemide is not working effectively.

3. Which intervention should be included for a client with heart failure?

• A. Encourage increased fluid intake
• B. Weigh the client daily to monitor fluid balance
• C. Restrict fluid intake during meals
• D. Limit daily activity to prevent fatigue

Correct answer: B

Rationale: Weighing the client daily to monitor fluid balance is crucial for clients with heart failure. This intervention helps assess for fluid retention or depletion, providing valuable information for managing the condition effectively. Encouraging increased fluid intake (Choice A) is contraindicated in heart failure as it can worsen fluid overload. Restricting fluid intake during meals (Choice C) may lead to dehydration, which is harmful for clients with heart failure. Limiting daily activity (Choice D) is not recommended as appropriate activity levels should be encouraged for overall well-being, under guidance to prevent excessive fatigue.

4. What are the common signs and symptoms of dehydration in the elderly?

• A. Dry mouth, confusion, and decreased skin turgor
• B. Increased heart rate and muscle cramps
• C. Fever, rapid breathing, and increased urine output
• D. Increased thirst and difficulty walking

Correct answer: A

Rationale: Corrected Rationale: Dehydration in the elderly is often signaled by dry mouth, confusion, and decreased skin turgor due to reduced fluid intake. Choice A is the correct answer as these are common signs and symptoms of dehydration in the elderly.\nIncorrect Rationales: Option B (Increased heart rate and muscle cramps) are more associated with conditions like hyperthyroidism or electrolyte imbalances rather than dehydration. Option C (Fever, rapid breathing, and increased urine output) are signs of other medical conditions such as infections or diabetes insipidus. Option D (Increased thirst and difficulty walking) can be seen in various situations but are not specific signs of dehydration in the elderly.

5. What are the side effects of chemotherapy, and how should they be managed?

• A. Nausea, vomiting; manage with antiemetics
• B. Hair loss and anemia; manage with blood transfusions
• C. Diarrhea and fatigue; manage with hydration
• D. Weight gain and high blood pressure; manage with diuretics

Correct answer: A

Rationale: The correct side effects of chemotherapy mentioned in this question are nausea and vomiting. These side effects are commonly managed with antiemetics to improve the quality of life for patients undergoing chemotherapy. Choice B (Hair loss and anemia) is incorrect as hair loss and anemia are potential side effects of chemotherapy but are not addressed in this question. Choice C (Diarrhea and fatigue) is also incorrect as it does not match the side effects provided. Choice D (Weight gain and high blood pressure) is inaccurate as these are not typical side effects of chemotherapy.

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