Nursing Elites

1. A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach the client to lie in every other hour during the first 12 hours after admission?

• A. Side-lying on the left with the head elevated 10 degrees
• B. Side-lying on the left with the head elevated 35 degrees
• C. Side-lying on the right with the head elevated 10 degrees
• D. Side-lying on the right with the head elevated 35 degrees

Correct answer: A

Rationale: The correct position for a client with viral pneumonia affecting 2/3 of the right lung is side-lying on the left with the head elevated 10 degrees. This position helps maximize lung expansion and oxygenation in cases of pneumonia affecting the right lung. Choice B is incorrect as excessive elevation can put pressure on the lung, and choices C and D are incorrect as side-lying on the right would not be beneficial for a client with pneumonia in the right lung.

2. The nurse is caring for a 7-year-old with acute glomerulonephritis (AGN). Findings include moderate edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most appropriate?

• A. Decreased carbohydrates and fat
• B. Decreased sodium and potassium
• C. Increased potassium and protein
• D. Increased sodium and fluids

Correct answer: B

Rationale: The correct answer is 'Decreased sodium and potassium.' In acute glomerulonephritis, managing edema and oliguria is crucial. Reducing sodium and potassium intake helps achieve this by decreasing fluid retention and workload on the kidneys. Choice A, 'Decreased carbohydrates and fat,' is not directly related to managing AGN. Choice C, 'Increased potassium and protein,' is incorrect as increasing potassium can be harmful in kidney conditions. Choice D, 'Increased sodium and fluids,' is also incorrect as it can exacerbate edema and hypertension in AGN.

3. A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the health care provider?

• A. Light pink urine
• B. Occasional suprapubic cramping
• C. Minimal drainage into the urinary collection bag
• D. Complaints of the feeling of pulling on the urinary catheter

Correct answer: C

Rationale: In a client with an indwelling catheter and continuous bladder irrigation post TURP, minimal drainage into the urinary collection bag should be reported to the health care provider. This finding could indicate a blockage in the catheter or a complication that requires immediate attention. Light pink urine (choice A) is expected due to bladder irrigation. Occasional suprapubic cramping (choice B) is common post-TURP. Complaints of the feeling of pulling on the urinary catheter (choice D) may indicate discomfort but do not suggest an urgent issue like a potential blockage.

4. A client with a history of deep vein thrombosis (DVT) is being treated with anticoagulants. Which of these findings is most concerning to the nurse?

• A. Presence of bruising on the arms and legs
• B. The client reports new onset of severe headache
• C. The client reports pain and swelling in the calf
• D. The client reports increased urination

Correct answer: C

Rationale: The correct answer is C because pain and swelling in the calf can indicate a new or worsening DVT, requiring immediate attention. Bruising on the arms and legs may be a common side effect of anticoagulants but is not as concerning as a potential DVT. Severe headache may indicate other conditions like a migraine or hypertension and is not directly related to DVT. Increased urination is not typically associated with DVT and may point towards other health issues like diabetes or urinary tract infections.

5. A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) 4 hours ago. Labor is to be induced. At the time of the ROM the vital signs were T-99.8 degrees F, P-84, R-20, BP-130/78, and fetal heart tones (FHT) 148 beats/min. Which assessment findings taken now may be an early indication that the client is developing a complication of labor?

• A. FHT 168 beats/min
• B. Temperature 100 degrees Fahrenheit
• C. Cervical dilation of 4 cm
• D. BP 138/88

Correct answer: A

Rationale: The correct answer is A. Fetal heart rate elevation can indicate distress, making it an early sign of labor complications. Choices B, C, and D are not the best answers in this scenario. Choice B, an elevated temperature, could indicate infection but is not a direct sign of labor complications. Choice C, cervical dilation of 4 cm, is a normal part of labor progression for a primigravida. Choice D, a blood pressure of 138/88, falls within normal limits and is not an early indication of labor complications.

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