Nursing Elites

1. A nurse is caring for a client who is at 32 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?

• A. Blood pressure of 120/80 mm Hg
• B. Respiratory rate of 16/min
• C. 1+ protein in the urine
• D. Heart rate of 88/min

Correct answer: C

Rationale: The correct answer is C. 1+ protein in the urine is indicative of worsening preeclampsia and should be reported to the provider immediately. Elevated blood pressure (choice A) is expected in preeclampsia, but a reading of 120/80 mm Hg is within the normal range. A respiratory rate of 16/min (choice B) and a heart rate of 88/min (choice D) are also within normal limits and not indicative of worsening preeclampsia.

2. A nurse is assessing a newborn who is 1-day old and receiving phototherapy for jaundice. Which action should the nurse take?

• A. Feed the infant glucose water every 2 hours.
• B. Ensure the newborn wears a diaper.
• C. Keep the infant's head covered with a cap.
• D. Apply lotion to the newborn every 4 hours.

Correct answer: C

Rationale: The correct action for the nurse to take is to keep the infant's head covered with a cap. This helps regulate the newborn's body temperature during phototherapy. Option A, feeding the infant glucose water every 2 hours, is incorrect because it is not a standard intervention for newborns receiving phototherapy. Option B, ensuring the newborn wears a diaper, may be necessary for hygiene but is not directly related to phototherapy. Option D, applying lotion to the newborn every 4 hours, is unnecessary and not indicated for managing jaundice or phototherapy.

3. What is the best dietary recommendation for a patient with chronic liver disease?

• A. Low protein diet
• B. High protein diet
• C. Low sodium diet
• D. High sodium diet

Correct answer: A

Rationale: The best dietary recommendation for a patient with chronic liver disease is a low protein diet. In liver disease, the liver may have difficulty processing protein, leading to the accumulation of toxins like ammonia in the body. A low protein diet helps reduce the burden on the liver and minimizes the production of these harmful substances. High protein diets can exacerbate the condition by increasing the workload on the liver. A low sodium diet (Choice C) is also important for liver disease patients as excess sodium can contribute to fluid retention and swelling, but reducing protein intake is the primary focus in these cases.

4. A nurse is providing discharge instructions for a client who has osteoporosis. Which of the following instructions should the nurse include to prevent injury?

• A. Perform weight-bearing exercises.
• B. Avoid crossing the legs beyond the midline.
• C. Avoid sitting in one position for prolonged periods.
• D. Splint the affected area.

Correct answer: A

Rationale: The correct answer is A: Perform weight-bearing exercises. Weight-bearing exercises are crucial for preventing bone density loss in clients with osteoporosis. These exercises help strengthen bones and reduce the risk of fractures. Option B, avoiding crossing the legs beyond the midline, is not directly related to preventing injury in osteoporosis. Option C, avoiding sitting in one position for prolonged periods, is important for preventing pressure ulcers but does not specifically address preventing injury in osteoporosis. Option D, splinting the affected area, is not a standard recommendation for preventing injury in osteoporosis.

5. A nurse in an emergency department is caring for a client who reports cocaine use 1hr ago. Which of the following findings should the nurse expect?

• A. Hypotension
• B. Memory loss
• C. Slurred speech
• D. Elevated temperature

Correct answer: D

Rationale: The correct answer is D: Elevated temperature. Cocaine is a stimulant drug that can lead to an increase in body temperature. Hypotension (choice A) is less likely as cocaine tends to increase blood pressure. Memory loss (choice B) and slurred speech (choice C) are not typically immediate effects of recent cocaine use.

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