Nursing Elites

1. A nurse is assessing a client who is 4 hours postpartum. Which of the following findings should the nurse report to the provider?

• A. Lochia that is red and contains small clots.
• B. Fundus firm at the umbilicus.
• C. Fundus deviated to the right.
• D. Moderate perineal pain with swelling.

Correct answer: C

Rationale: The correct answer is C. A fundus that is deviated to the right may indicate a full bladder, which should be addressed postpartum. Choice A is incorrect because red lochia with small clots is expected during the early postpartum period. Choice B is incorrect as the fundus should be firm and midline, not at the umbilicus. Choice D is incorrect as perineal pain and swelling are common postpartum findings that do not require immediate reporting to the provider.

2. A client with diabetes mellitus is receiving discharge instructions from a nurse. Which statement by the client indicates an understanding of the teaching?

• A. I will monitor my blood sugar level once a week.
• B. I will exercise every day even if my blood sugar is low.
• C. I will eat snacks rich in carbohydrates if my blood sugar drops.
• D. I will avoid sugary foods to prevent my blood sugar from rising.

Correct answer: C

Rationale: The correct answer is C. Eating snacks rich in carbohydrates is essential to manage hypoglycemia by raising blood sugar levels. Option A is incorrect as monitoring blood sugar once a week is not frequent enough for effective diabetes management. Option B is incorrect because exercising when blood sugar is low can worsen hypoglycemia. Option D is incorrect as it focuses on preventing high blood sugar levels, not managing low blood sugar.

3. A nurse is caring for a client who is at risk for developing a deep vein thrombosis (DVT). Which of the following interventions should the nurse implement?

• A. Massage the client's legs every 2 hours.
• B. Instruct the client to sit with the legs crossed.
• C. Administer prophylactic antibiotics.
• D. Apply sequential compression devices to the client's legs.

Correct answer: D

Rationale: The correct answer is D: Apply sequential compression devices to the client's legs. Sequential compression devices help prevent venous stasis and reduce the risk of DVT by promoting blood flow in the legs. Massaging the client's legs every 2 hours (choice A) may dislodge a clot if present, leading to a higher risk of embolism. Instructing the client to sit with the legs crossed (choice B) can impede blood flow and increase the risk of DVT. Administering prophylactic antibiotics (choice C) is not indicated for preventing DVT, as antibiotics are used to treat infections caused by bacteria, not to prevent blood clots.

4. A nurse is caring for a client who wears glasses. What action should the nurse take?

• A. Store the glasses in a labeled case.
• B. Clean the glasses with hot water.
• C. Clean the glasses with a paper towel.
• D. Store the glasses on the bedside table.

Correct answer: A

Rationale: The correct action for the nurse to take is to store the glasses in a labeled case. This helps prevent damage and loss of the glasses, ensuring they are kept safe when not in use. Cleaning the glasses with hot water (choice B) can damage the lenses or frames, while cleaning with a paper towel (choice C) might lead to scratches. Storing the glasses on the bedside table (choice D) increases the risk of misplacement or damage.

5. A client with schizophrenia starting therapy with clozapine is being discharged. Which symptom should the client report to the provider as the highest priority?

• A. Constipation
• B. Blurred vision
• C. Fever
• D. Dry mouth

Correct answer: C

Rationale: The correct answer is C: Fever. When a client is taking clozapine, fever can indicate serious conditions such as infection or severe reactions, which need immediate medical attention. Constipation (choice A), blurred vision (choice B), and dry mouth (choice D) are common side effects of clozapine but are not as urgent as fever. Constipation can be managed with dietary changes or medications, blurred vision can improve over time, and dry mouth can be relieved with frequent sips of water.

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