Nursing Elites

1. A client with type 2 diabetes mellitus is concerned about weight gain during pregnancy. Which of the following responses should the nurse make?

• A. Your weight gain should be less than that for someone without diabetes.
• B. Your weight gain should be the same as that for someone without diabetes.
• C. You should not avoid gaining weight during pregnancy.
• D. You should gain more weight to support the pregnancy.

Correct answer: B

Rationale: During pregnancy, a client with type 2 diabetes mellitus should aim for a weight gain similar to someone without diabetes to ensure a healthy pregnancy. Choice A is incorrect because weight gain should not be less; it should be adequate for pregnancy. Choice C is inaccurate as gaining some weight is essential for a healthy pregnancy. Choice D is incorrect as gaining more weight than necessary can pose risks for both the client and the baby.

2. A client who is postoperative following a cholecystectomy has a urine output of 25 mL/hr. Which of the following findings should the nurse report to the provider?

• A. Abdominal pain radiating to the right shoulder.
• B. Absent bowel sounds.
• C. Brown drainage on the surgical dressing.
• D. Urine output of 25 mL/hr.

Correct answer: D

Rationale: A urine output below 30 mL/hr indicates a potential complication, such as hypovolemia or renal impairment, and should be reported. Abdominal pain radiating to the right shoulder can be common after a cholecystectomy due to referred pain from the diaphragm, whereas absent bowel sounds may be expected temporarily postoperatively. Brown drainage on the surgical dressing is typical in the early postoperative period and may represent old blood or other normal discharge.

3. What are the signs and symptoms of fluid overload?

• A. Edema, shortness of breath, weight gain
• B. High blood pressure and jugular venous distention
• C. Low blood pressure and cyanosis
• D. Tachycardia and dizziness

Correct answer: A

Rationale: The correct signs and symptoms of fluid overload include edema, shortness of breath, and weight gain. Edema is the abnormal accumulation of fluid causing swelling, shortness of breath can occur due to fluid accumulating in the lungs, and weight gain is often seen as a result of excess fluid retention. Choices B, C, and D are incorrect because high blood pressure and jugular venous distention are more indicative of conditions like heart failure, while low blood pressure and cyanosis are seen in conditions like shock or poor perfusion. Tachycardia and dizziness are not typical signs of fluid overload.

4. A client has developed phlebitis at the IV site. What is the next step the nurse should take?

• A. Administer an anti-inflammatory medication
• B. Discontinue the IV and notify the provider
• C. Apply a cold compress over the IV site
• D. Increase the IV flow rate to prevent dehydration

Correct answer: B

Rationale: When a client develops phlebitis at the IV site, the nurse's immediate action should be to discontinue the IV and notify the healthcare provider. Phlebitis is inflammation of the vein, and leaving the IV in place can lead to complications such as infection or thrombosis. Administering an anti-inflammatory medication (choice A) may not address the root cause and delay the necessary intervention. Applying a cold compress (choice C) may provide temporary relief but does not address the need to remove the source of inflammation. Increasing the IV flow rate (choice D) is contraindicated as it can exacerbate the phlebitis by causing more irritation to the vein.

5. A nurse assisting with a childbirth class is discussing nonpharmacological strategies used during labor. Which of the following statements by a client indicates an understanding of cutaneous stimulation?

• A. Apply counter-pressure for back pain
• B. Use deep breathing exercises
• C. Visualize the baby's head
• D. Use massage therapy

Correct answer: A

Rationale: The correct answer is A: 'Apply counter-pressure for back pain.' Counter-pressure involves applying pressure to the lower back to alleviate pain during labor. This technique is a form of cutaneous stimulation, which can help with pain relief. Choice B, deep breathing exercises, is a form of relaxation technique and does not directly involve cutaneous stimulation. Choice C, visualizing the baby's head, is a mental imagery technique and does not involve physical stimulation of the skin. Choice D, massage therapy, is a tactile stimulation technique but is not specifically focused on back pain relief through counter-pressure.

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