Nursing Elites

1. A client receiving oxytocin IV for labor augmentation is experiencing contractions every 45 seconds. What action should the nurse take?

• A. Discontinue the oxytocin infusion
• B. Increase the oxytocin infusion
• C. Decrease the oxytocin infusion
• D. Maintain the oxytocin infusion

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to discontinue the oxytocin infusion. Contractions occurring every 45 seconds indicate uterine hyperstimulation, which can pose risks to both the client and the fetus. By stopping the oxytocin infusion, the nurse can help prevent further complications. Choices B, C, and D are incorrect because increasing, decreasing, or maintaining the oxytocin infusion can exacerbate the uterine hyperstimulation and increase the risks associated with it.

2. A client with heart failure who presents with dyspnea, bibasilar crackles, and frothy sputum should receive which dietary recommendation?

• A. Decrease protein intake.
• B. Reduce sodium intake.
• C. Increase fluid intake.
• D. Decrease calcium intake.

Correct answer: B

Rationale: The correct answer is to reduce sodium intake. In heart failure, excess sodium can lead to fluid retention, exacerbating symptoms like dyspnea, bibasilar crackles, and frothy sputum. Therefore, reducing sodium intake is crucial in managing heart failure. Decreasing protein intake is not typically recommended in heart failure management. Increasing fluid intake would worsen the condition by further contributing to fluid overload. Decreasing calcium intake is not directly related to managing heart failure symptoms such as dyspnea, bibasilar crackles, and frothy sputum.

3. A healthcare provider is educating a client about the use of montelukast. Which of the following should be included?

• A. It is used for acute asthma attacks
• B. It is taken once daily in the evening
• C. It should be taken with food
• D. It has no side effects

Correct answer: B

Rationale: The correct answer is B. Montelukast is a leukotriene receptor antagonist that is typically taken once daily in the evening for asthma management. Choice A is incorrect as montelukast is not used for acute asthma attacks but rather for the prevention of asthma symptoms. Choice C is also incorrect because montelukast can be taken with or without food. Choice D is misleading as all medications, including montelukast, have potential side effects.

4. A client just received the first dose of lisinopril. Which of the following is an appropriate nursing intervention?

• A. Place the client on cardiac monitoring
• B. Monitor the client's oxygen saturation level
• C. Provide standby assistance when getting out of bed
• D. Encourage foods high in potassium

Correct answer: C

Rationale: The correct answer is to provide standby assistance when getting out of bed. Lisinopril can cause first-dose hypotension, leading to dizziness and increasing the risk of falls. Standby assistance helps ensure the client's safety when mobilizing. Placing the client on cardiac monitoring (choice A) is not necessary unless there are specific indications for cardiac monitoring. Monitoring oxygen saturation (choice B) is not directly related to the side effects of lisinopril. Encouraging foods high in potassium (choice D) is not the most immediate or appropriate intervention following the administration of lisinopril.

5. A client who has a new prescription for simvastatin is receiving teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?

• A. I will take this medication in the morning.
• B. I should avoid drinking grapefruit juice while taking this medication.
• C. I should expect my cholesterol levels to increase initially.
• D. I will need to have my kidney function checked every 3 months.

Correct answer: B

Rationale: The correct answer is B. Grapefruit juice can increase the risk of toxicity with simvastatin, so clients should avoid consuming it while on the medication. Choice A is incorrect because the timing of medication administration should be based on healthcare provider instructions. Choice C is incorrect because simvastatin is prescribed to lower cholesterol levels. Choice D is incorrect as monitoring kidney function is not specifically related to simvastatin therapy.

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