Nursing Elites

1. A nurse is providing dietary teaching to a client who is at 8 weeks of gestation and has a body mass index (BMI) of 24. Which of the following instructions should the nurse include?

• A. You should increase your caloric intake by 600 calories per day.
• B. You should increase your caloric intake by 300 calories per day.
• C. You should maintain your prepregnancy caloric intake during the first trimester.
• D. You should increase your caloric intake by 150 calories per day.

Correct answer: B

Rationale: During the first trimester, it is recommended to increase caloric intake by 300 calories per day to support fetal growth and development. Choice A suggesting an increase of 600 calories is excessive and unnecessary. Choice C advising to maintain prepregnancy caloric intake could lead to inadequate nutrition for the developing fetus. Choice D recommending an increase of 150 calories is insufficient to meet the increased energy demands of pregnancy.

2. While caring for a client receiving hemodialysis, which action should the nurse include in the plan of care?

• A. Withhold all medications until after dialysis.
• B. Check the vascular access site for bleeding after dialysis.
• C. Rehydrate with dextrose 5% in water for hypotension.
• D. Give an antibiotic 30 minutes before dialysis.

Correct answer: B

Rationale: The correct action the nurse should include in the plan of care when caring for a client receiving hemodialysis is to check the vascular access site for bleeding after dialysis. This is crucial to monitor for any signs of bleeding or complications at the access site. Withholding all medications until after dialysis (Choice A) is not necessary unless specified for certain medications. Rehydrating with dextrose 5% in water for hypotension (Choice C) is not appropriate for addressing hypotension related to hemodialysis. Giving an antibiotic 30 minutes before dialysis (Choice D) is not typically indicated unless there is a specific medical indication for prophylactic antibiotic use.

3. A nurse is caring for a client who has septic shock. Which of the following findings should the nurse report to the provider?

• A. Temperature of 38°C (100.4°F).
• B. Urinary output of 40 mL/hr.
• C. Heart rate of 92/min.
• D. Capillary refill time of 2 seconds.

Correct answer: B

Rationale: The correct answer is B. A urinary output of 40 mL/hr is below the expected range and should be reported to the provider as it may indicate impaired kidney function, which is crucial to monitor in a client with septic shock. Choices A, C, and D are within acceptable ranges for a client with septic shock and do not indicate immediate concerns. A temperature of 38°C (100.4°F) is slightly elevated but can be expected in septic shock. A heart rate of 92/min is within the normal range for an adult. A capillary refill time of 2 seconds is also normal, indicating adequate peripheral perfusion.

4. A nurse is teaching a client about self-administration of enoxaparin. Which of the following instructions should the nurse include?

• A. Administer the injection into the muscle of your thigh.
• B. Pinch the skin before inserting the needle.
• C. Rub the injection site after administering the medication.
• D. Administer the injection into the fat tissue of your abdomen.

Correct answer: D

Rationale: The correct instruction for self-administration of enoxaparin is to inject it into the fat tissue of the abdomen for proper absorption. Choice A is incorrect as enoxaparin should not be injected into the muscle. Choice B is unnecessary for enoxaparin administration. Choice C is incorrect as rubbing the injection site after administering the medication is not recommended.

5. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following actions should the nurse take?

• A. Request a renewal of the prescription every 8 hours.
• B. Check the client's peripheral pulse rate every 30 minutes.
• C. Obtain a prescription for restraint within 4 hours.
• D. Document the client's condition every 15 minutes.

Correct answer: C

Rationale: Obtaining a prescription for restraint within 4 hours is the correct action when managing restraints in a client with acute mania. This timeframe ensures that the use of restraints is promptly evaluated and authorized by a healthcare provider. Requesting a renewal of the prescription every 8 hours (Choice A) is not necessary and may delay appropriate care. Checking the client's peripheral pulse rate every 30 minutes (Choice B) is important but not the immediate priority when dealing with obtaining a prescription for restraints. Documenting the client's condition every 15 minutes (Choice D) is essential for monitoring, but the priority is to secure a prescription for restraints promptly.

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