Nursing Elites

1. A client tells the nurse that she suspects she is pregnant because she is able to feel the baby move. The nurse knows that this is a:

• A. Presumptive sign of pregnancy
• B. Probable sign of pregnancy
• C. Positive sign of pregnancy
• D. Possible sign of pregnancy

Correct answer: A

Rationale: The correct answer is A: Presumptive sign of pregnancy. Quickening, or the sensation of fetal movement, is considered a presumptive sign of pregnancy. It is not definitive because other conditions, such as gas or intestinal movement, can mimic the feeling of fetal movement. Choice B, Probable sign of pregnancy, refers to signs that make the nurse reasonably certain that a woman is pregnant, such as a positive pregnancy test. Choice C, Positive sign of pregnancy, includes signs like hearing fetal heart tones or visualizing the fetus on ultrasound, which definitively confirm pregnancy. Choice D, Possible sign of pregnancy, is a vague term and does not specifically relate to any pregnancy sign.

2. A client is being educated by a nurse about the use of carbidopa-levodopa. Which of the following should be included?

• A. It will cure Parkinson's disease
• B. Monitor for dyskinesia
• C. It can be taken with food
• D. It is an opioid medication

Correct answer: B

Rationale: The correct answer is to 'Monitor for dyskinesia.' Carbidopa-levodopa can cause dyskinesia as a side effect, characterized by involuntary movements. Monitoring for this side effect is crucial. Choice A is incorrect because carbidopa-levodopa helps manage symptoms of Parkinson's disease but does not cure it. Choice C is incorrect because carbidopa-levodopa should be taken on an empty stomach to enhance absorption. Choice D is incorrect because carbidopa-levodopa is not an opioid medication.

3. A nurse is planning care for a client who has a latex allergy and is scheduled for surgery. Which of the following actions should the nurse take?

• A. Apply tape to the client’s skin before surgery.
• B. Ensure the surgical suite is well-ventilated.
• C. Wrap monitoring cords with stockinette.
• D. Schedule the surgery at the end of the day.

Correct answer: C

Rationale: The correct action the nurse should take is to wrap monitoring cords with stockinette. This measure ensures that the latex in the cords does not come into contact with the client’s skin, reducing the risk of an allergic reaction. Applying tape to the client’s skin before surgery (Choice A) may expose the client to latex if the tape contains latex. Ensuring the surgical suite is well-ventilated (Choice B) is important for overall safety but does not specifically address the client's latex allergy. Scheduling the surgery at the end of the day (Choice D) is not directly related to preventing latex exposure and allergic reactions.

4. A nurse is caring for a client who has liver cirrhosis and ascites. Which of the following actions should the nurse take to monitor the effectiveness of the treatment?

• A. Measure the client’s abdominal girth daily
• B. Monitor the client’s hemoglobin level
• C. Administer lactulose as prescribed
• D. Weigh the client weekly

Correct answer: A

Rationale: Measuring the client’s abdominal girth daily is the most effective way to monitor the reduction of ascites and fluid retention in clients with liver cirrhosis. This measurement helps assess the effectiveness of treatment in managing ascites by monitoring changes in abdominal size. Monitoring the client’s hemoglobin level (Choice B) is not directly related to assessing the effectiveness of ascites treatment. Administering lactulose as prescribed (Choice C) is important in managing hepatic encephalopathy, not ascites. Weighing the client weekly (Choice D) may not provide real-time feedback on the reduction of ascites compared to daily abdominal girth measurements.

5. A nurse is caring for a client who has a peripherally inserted central catheter (PICC). For which of the following findings should the nurse notify the provider?

• A. The dressing was changed 7 days ago
• B. The circumference of the client’s upper arm has increased by 10%
• C. The catheter has not been used in 8 hours
• D. The catheter has been flushed with 10 mL of sterile saline after medication use

Correct answer: B

Rationale: The correct answer is B. The circumference of the upper arm above the insertion site of the PICC should be measured at the time of insertion and then again during assessments. An increase in circumference could indicate deep vein thrombosis, which could be life-threatening. Choice A is not a concern as changing the dressing 7 days ago is within the recommended timeframe. Choice C is not alarming as the catheter not being used for 8 hours does not necessarily indicate a problem. Choice D indicates proper catheter care by flushing it with sterile saline after medication use, so it does not require provider notification.

Similar Questions