Nursing Elites

1. A nurse is planning care for a client who has cirrhosis. Which of the following interventions should the nurse include?

• A. Limit the client's sodium intake to 4 grams per day.
• B. Measure the client's abdominal girth daily.
• C. Monitor the client's urine specific gravity every 12 hours.
• D. Encourage the client to drink 3 liters of fluid per day.

Correct answer: B

Rationale: The correct answer is to measure the client's abdominal girth daily. Measuring abdominal girth helps monitor for ascites, a common complication of cirrhosis. Limiting sodium intake is important in cirrhosis but there is no specific value given, making choice A less precise. Monitoring urine specific gravity is not directly related to cirrhosis management, making choice C incorrect. Encouraging the client to drink 3 liters of fluid per day may not be suitable for all patients with cirrhosis, especially those with fluid restrictions, so choice D is not the most appropriate intervention.

2. A client with Raynaud's disease is being cared for by a nurse. What intervention should the nurse implement?

• A. Maintain a warm temperature in the client's room.
• B. Administer epinephrine for acute episodes.
• C. Provide information about stress management.
• D. Give glucocorticoid steroid twice a day.

Correct answer: C

Rationale: The correct intervention for a client with Raynaud's disease is to provide information about stress management. Stress can trigger Raynaud's episodes, so managing stress can help reduce the frequency and severity of the condition. Maintaining a warm temperature in the client's room (Choice A) is important to prevent vasoconstriction and worsening of symptoms. Administering epinephrine (Choice B) is not a standard treatment for Raynaud's disease. Giving glucocorticoid steroids (Choice D) is not the primary treatment for Raynaud's disease and is not typically prescribed for this condition.

3. A nurse is assessing a client who is in active labor. The FHR baseline has been 100/min for the past 15 minutes. What condition should the nurse suspect?

• A. Maternal fever.
• B. Fetal anemia.
• C. Maternal hypoglycemia.
• D. Chorioamnionitis.

Correct answer: C

Rationale: In this scenario, the FHR baseline of 100/min for the past 15 minutes indicates fetal bradycardia, which can be caused by maternal hypoglycemia. Maternal hypoglycemia can lead to decreased oxygen supply to the fetus, resulting in fetal bradycardia. Maternal fever (Choice A) typically presents with tachycardia in the fetus rather than bradycardia. Fetal anemia (Choice B) is more likely to manifest as tachycardia due to compensation for decreased oxygen delivery. Chorioamnionitis (Choice D) may lead to fetal tachycardia as a sign of fetal distress, not bradycardia.

4. The healthcare provider is reviewing the medical record of a client who is requesting combination oral contraceptives. Which of the following conditions in the client's history is a contraindication to the use of oral contraceptives?

• A. Hyperthyroidism
• B. Thrombophlebitis
• C. Diverticulosis
• D. Hypocalcemia

Correct answer: B

Rationale: Thrombophlebitis is a condition characterized by inflammation of a vein, which increases the risk of blood clots. The use of oral contraceptives further elevates the risk of clot formation, making them contraindicated in individuals with thrombophlebitis. Hyperthyroidism (Choice A), diverticulosis (Choice C), and hypocalcemia (Choice D) are not contraindications to the use of oral contraceptives.

5. A nurse is assessing a client who has a chest tube. Which of the following findings should the nurse report to the provider?

• A. Constant bubbling in the water seal chamber.
• B. Intermittent bubbling in the suction control chamber.
• C. Tidaling in the water seal chamber.
• D. Drainage of 75 mL in the first 24 hours.

Correct answer: A

Rationale: The correct answer is A: Constant bubbling in the water seal chamber. Constant bubbling in the water seal chamber can indicate an air leak, which compromises the integrity of the chest tube system and should be reported to the provider for immediate intervention. Choices B, C, and D are incorrect. Intermittent bubbling in the suction control chamber is an expected finding indicating that the system is working appropriately. Tidaling in the water seal chamber is a normal fluctuation of fluid level with inspiration and expiration, indicating that the system is functioning correctly. Drainage of 75 mL in the first 24 hours is within the expected range for chest tube drainage and does not require immediate reporting unless accompanied by other concerning symptoms.

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