Nursing Elites

1. A nurse is caring for a client who is 36 weeks gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?

• A. Proteinuria of 1+.
• B. Blood pressure 120/80 mm Hg.
• C. Respiratory rate of 18/min.
• D. Nonpitting ankle edema.

Correct answer: D

Rationale: Nonpitting ankle edema is a concerning sign of worsening preeclampsia due to fluid retention and should be reported immediately. Proteinuria of 1+ is a common finding in preeclampsia. A blood pressure of 120/80 mm Hg is within normal limits. A respiratory rate of 18/min is also within normal range. Therefore, choices A, B, and C are not as urgent as nonpitting ankle edema in this scenario.

2. A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?

• A. Contractions lasting 80 seconds.
• B. FHR baseline 170/min.
• C. Early decelerations in the FHR.
• D. Temperature 37.4°C (99.3°F).

Correct answer: B

Rationale: The correct answer is B. An FHR baseline of 170/min is considered tachycardia, which is above the normal range during labor and requires immediate attention. High FHR can indicate fetal distress or maternal fever. Choice A, contractions lasting 80 seconds, are within normal range for active labor. Choice C, early decelerations in the FHR, are usually benign and do not typically require immediate intervention. Choice D, a temperature of 37.4°C (99.3°F), is within normal limits.

3. A healthcare provider is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome (IBS). Which of the following foods should the healthcare provider instruct the client to avoid?

• A. Lean cuts of pork.
• B. Low-fat yogurt.
• C. White bread.
• D. Oatmeal.

Correct answer: D

Rationale: The correct answer is D, oatmeal. Oatmeal contains insoluble fiber, which can exacerbate the symptoms of irritable bowel syndrome. Choices A, B, and C are not typically problematic for individuals with IBS. Lean cuts of pork, low-fat yogurt, and white bread are generally well-tolerated and may even be recommended as part of a balanced diet for individuals with IBS.

4. A nurse is teaching a client who has a new prescription for clopidogrel. Which of the following statements should the nurse include?

• A. You should avoid drinking alcohol while taking this medication.
• B. You should monitor for signs of infection.
• C. Take this medication with food to prevent gastrointestinal upset.
• D. Take this medication with a full glass of water.

Correct answer: B

Rationale: The correct statement the nurse should include when teaching a client taking clopidogrel is to monitor for signs of infection. Clopidogrel affects platelet levels and can increase the risk of bleeding. Monitoring for signs of infection is crucial because a compromised immune system can make the client more susceptible to infections. Choices A, C, and D are incorrect because clopidogrel is not directly linked to alcohol restrictions, food requirements, or specific water intake instructions.

5. What is the primary nursing intervention for a patient experiencing hypoglycemia?

• A. Administer IV fluids
• B. Check blood sugar levels
• C. Provide oral glucose
• D. Recheck blood sugar levels in 15 minutes

Correct answer: D

Rationale: The correct answer is to recheck blood sugar levels in 15 minutes. This intervention is crucial to ensure that the hypoglycemia has been effectively corrected after the initial treatment. Administering IV fluids may be necessary in cases of severe dehydration but is not the primary intervention for hypoglycemia. Checking blood sugar levels is important, but the primary intervention should focus on treating the low blood sugar levels first, which is done by providing oral glucose. However, the most critical step after providing initial treatment is to recheck blood sugar levels to confirm that they have improved to safe levels.

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