Nursing Elites

1. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate. The nurse should monitor the client for which of the following findings as an indication of magnesium toxicity?

• A. Decreased deep tendon reflexes
• B. Elevated blood pressure
• C. Increased urinary output
• D. Hyperreflexia

Correct answer: A

Rationale: The correct answer is A: Decreased deep tendon reflexes. Magnesium sulfate toxicity can lead to diminished deep tendon reflexes, respiratory depression, and decreased urine output. Diminished deep tendon reflexes are an early sign of magnesium toxicity and indicate the need to discontinue the infusion. Elevated blood pressure (choice B) is not typically associated with magnesium toxicity. Increased urinary output (choice C) is also not a common finding in magnesium toxicity. Hyperreflexia (choice D) is not consistent with the expected findings of magnesium toxicity, which typically causes decreased reflexes.

2. A client with chronic kidney disease is about to start hemodialysis. Which of the following instructions should the nurse include?

• A. Increase protein intake between dialysis sessions
• B. Reduce potassium intake
• C. Avoid iron supplements
• D. Expect weight gain after each dialysis session

Correct answer: B

Rationale: The correct answer is to instruct the client to reduce potassium intake. Clients with chronic kidney disease should limit potassium intake to prevent hyperkalemia, as the kidneys may struggle to remove excess potassium. Increasing protein intake between dialysis sessions (Choice A) is not recommended as it can increase urea production, adding to the workload of the kidneys. Avoiding iron supplements (Choice C) is not necessary unless iron levels are high. Expecting weight gain after each dialysis session (Choice D) is incorrect as patients typically experience weight loss due to fluid removal during dialysis.

3. A nurse is preparing to administer enoxaparin to a client. Which of the following actions should the nurse take?

• A. Aspirate before injecting
• B. Massage the site after injecting
• C. Administer the injection in the abdomen
• D. Inject at a 90-degree angle

Correct answer: C

Rationale: The correct action the nurse should take when administering enoxaparin is to inject the medication in the abdomen subcutaneously. This route ensures proper absorption of the medication. Aspiration is not necessary before injecting enoxaparin as it is a subcutaneous injection, not an intramuscular injection. Massaging the site after injecting should be avoided to prevent bruising. Enoxaparin injections are typically given at a 45 to 90-degree angle, not necessarily at a strict 90-degree angle.

4. A nurse is teaching a client about the dietary management of irritable bowel syndrome (IBS). Which of the following instructions should the nurse include?

• A. Decrease fiber intake
• B. Drink peppermint tea
• C. Increase foods that are high in fat
• D. Avoid foods with gluten

Correct answer: B

Rationale: The correct answer is B: 'Drink peppermint tea.' Peppermint tea can help relax the smooth muscles of the gastrointestinal tract, reducing symptoms of IBS, such as bloating and abdominal discomfort. Choices A, C, and D are incorrect. Decreasing fiber intake is not recommended for IBS management as fiber can help regulate bowel movements. Increasing foods high in fat can exacerbate symptoms of IBS, as high-fat foods can be harder to digest. Avoiding foods with gluten is more relevant for individuals with gluten sensitivity or celiac disease, not specifically for IBS management.

5. A nurse is caring for a client with celiac disease. Which food should be removed from the meal tray?

• A. Cornbread
• B. Mashed potatoes
• C. Lentils
• D. Tortillas

Correct answer: D

Rationale: The correct answer is D, Tortillas. Clients with celiac disease should avoid gluten, which is often found in tortillas. Cornbread, mashed potatoes, and lentils are gluten-free options, making them safe for individuals with celiac disease. Therefore, the other choices (A, B, and C) do not need to be removed from the meal tray.

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