Nursing Elites

1. A nurse is caring for a client who is 36 weeks pregnant and reports leaking fluid. Which of the following tests should the nurse use to confirm that the client's membranes have ruptured?

• A. Nonstress test
• B. Biophysical profile
• C. Fern test
• D. Amniocentesis

Correct answer: C

Rationale: The correct answer is the Fern test. The Fern test is specifically used to confirm the rupture of membranes. A sample of vaginal fluid is examined under a microscope, and the presence of a fern-like pattern indicates the presence of amniotic fluid. The Nonstress test (Choice A) is used to monitor fetal heart rate and movement, not to confirm ruptured membranes. The Biophysical profile (Choice B) is a prenatal ultrasound evaluation to assess fetal well-being, not to confirm ruptured membranes. Amniocentesis (Choice D) involves the aspiration of amniotic fluid for various diagnostic purposes, not specifically to confirm ruptured membranes.

2. A nurse is planning care for a client who has chronic renal failure. Which action should the nurse include in the plan of care?

• A. Encourage increased fluid intake
• B. Restrict protein intake to the RDA
• C. Increase dietary potassium
• D. Encourage foods high in sodium

Correct answer: B

Rationale: The correct action the nurse should include in the plan of care for a client with chronic renal failure is to restrict protein intake to the RDA. This is important because limiting protein helps reduce the buildup of waste products that the kidneys are unable to efficiently excrete. Encouraging increased fluid intake (choice A) may further burden the kidneys, increasing the risk of fluid overload. Increasing dietary potassium (choice C) is not recommended in chronic renal failure as impaired kidneys have difficulty regulating potassium levels. Encouraging foods high in sodium (choice D) is also not appropriate as excessive sodium intake can lead to fluid retention and hypertension, which are detrimental in renal failure.

3. A client is being taught how to use a PCA pump postoperatively. Which statement indicates understanding?

• A. I should wait until the pain is severe before using the PCA pump.
• B. My family can press the button for me when I'm asleep.
• C. I will press the button when I start to feel pain.
• D. I will only press the button once per hour.

Correct answer: C

Rationale: The correct answer is C because the client should press the PCA pump button when they start to feel pain. This approach helps maintain pain control effectively. Choice A is incorrect because waiting for the pain to become severe before using the PCA pump can lead to inadequate pain management. Choice B is incorrect because only the client should operate the PCA pump to ensure the correct dosage is administered. Choice D is incorrect because the client should press the button as needed when experiencing pain, rather than limiting its use to once per hour.

4. A nurse is preparing to administer a dose of escitalopram. Which of the following should the nurse assess first?

• A. Mood changes
• B. Blood pressure
• C. Heart rate
• D. Liver function

Correct answer: A

Rationale: The correct answer is to assess for mood changes. When administering escitalopram, it is crucial to evaluate mood changes first because the medication may take some time to demonstrate its full effects on the patient's mood. Assessing blood pressure, heart rate, or liver function is not the priority when administering escitalopram, as these parameters are not directly impacted acutely by this medication.

5. A client is prescribed furosemide. Which of the following is a potential side effect?

• A. Hyperkalemia
• B. Hypokalemia
• C. Hyponatremia
• D. Hypernatremia

Correct answer: B

Rationale: The correct answer is B: Hypokalemia. Furosemide is a loop diuretic that can lead to potassium loss through urine, causing hypokalemia. Hyperkalemia (choice A) is not a side effect of furosemide. Hyponatremia (choice C) and hypernatremia (choice D) are related to sodium levels rather than potassium, and they are not typically associated with furosemide use.

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