Nursing Elites

1. A nurse is caring for a client who is at 38 weeks of gestation and is experiencing continuous abdominal pain and vaginal bleeding. The client has a history of cocaine use. The nurse should identify that the client is likely experiencing which of the following complications?

• A. Abruptio placentae
• B. Hydatidiform mole
• C. Preterm labor
• D. Placenta previa

Correct answer: A

Rationale: Continuous abdominal pain and vaginal bleeding in a client with a history of cocaine use suggest abruptio placentae, where the placenta detaches from the uterus prematurely, posing serious risks to both mother and fetus. Hydatidiform mole is characterized by abnormal trophoblastic tissue growth, not continuous pain and bleeding. Preterm labor is premature contractions leading to birth before 37 weeks gestation. Placenta previa involves the placenta partially or completely covering the cervix, presenting with painless vaginal bleeding.

2. A nurse is assessing a newborn following a vaginal delivery. Which of the following findings should the nurse report to the provider?

• A. Vernix caseosa
• B. Head circumference of 34 cm
• C. Jaundice at 24 hours of age
• D. Respiratory rate of 50/min

Correct answer: C

Rationale: Jaundice within the first 24 hours of life is considered pathological and may indicate hemolytic disease or another serious condition, requiring further investigation.

3. A nurse is preparing to administer furosemide to a client who has a prescription. Which of the following statements by the client indicates a need for further teaching?

• A. I will take my morning pills with food or milk.
• B. I will weigh myself every day.
• C. I will notify the nurse if I have muscle cramps.
• D. I will limit my intake of fish.

Correct answer: D

Rationale: The correct answer is D. There is no need to limit fish intake with furosemide, indicating a misunderstanding of dietary restrictions. Furosemide is a diuretic that helps the body get rid of excess water and salt. Choices A, B, and C are all appropriate actions for a client taking furosemide. Taking morning pills with food or milk can help reduce stomach upset, weighing oneself daily helps monitor fluid retention, and notifying the nurse about muscle cramps can be important due to potential electrolyte imbalances.

4. A nurse is preparing to perform a sterile dressing change for a client with a surgical wound. Which action should the nurse take to prevent contamination during the dressing change?

• A. Proceed with the dressing change
• B. Restart the procedure if the sterile solution splashes onto the sterile field
• C. Continue without concern for minor splashes
• D. Delegate the task to another nurse

Correct answer: B

Rationale: The correct action for the nurse to take to prevent contamination during a sterile dressing change is to restart the procedure if the sterile solution splashes onto the sterile field. Any contamination of the sterile field compromises the aseptic technique and increases the risk of infection for the client. Therefore, it is crucial to maintain the sterility of the field throughout the procedure. Choices A, C, and D are incorrect because proceeding with the dressing change, continuing without concern for minor splashes, or delegating the task to another nurse would all compromise the sterility of the procedure and increase the risk of infection for the client.

5. A nurse is providing discharge teaching to a client with heart failure and a prescription for furosemide 20 mg PO twice daily. Which of the following instructions should the nurse include in the teaching?

• A. Monitor for increased blood pressure
• B. Increase intake of high-potassium foods
• C. Expect an increase in swelling in the hands and feet
• D. Take the second dose at bedtime

Correct answer: B

Rationale: The correct answer is B: "Increase intake of high-potassium foods." Furosemide is a loop diuretic that can lead to hypokalemia, a condition characterized by low potassium levels. To prevent this adverse effect, the client should increase their intake of high-potassium foods. Choice A is incorrect because furosemide typically leads to decreased blood pressure, not increased. Choice C is incorrect because furosemide is used to reduce swelling, not increase it. Choice D is incorrect because the second dose of furosemide should be taken in the morning to prevent nocturia.

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