Nursing Elites

1. A client who has undergone a cesarean birth is receiving discharge instructions from a nurse. Which of the following should the nurse include in the instructions?

• A. Limit stair climbing for the first few weeks
• B. Avoid lifting anything heavier than the newborn
• C. Use a pillow to support the abdomen when coughing or sneezing
• D. All of the above

Correct answer: D

Rationale: After a cesarean birth, it is important for the client to follow specific instructions for optimal recovery. Limiting stair climbing reduces strain on the incision site, aiding in healing (Choice A). Avoiding lifting anything heavier than the newborn prevents stress on the incision, promoting recovery (Choice B). Using a pillow to support the abdomen during coughing or sneezing helps reduce discomfort and protect the incision, preventing sudden movements or strain (Choice C). Therefore, all the options provided are crucial post-cesarean birth instructions to ensure proper healing and recovery. Choices A, B, and C are all essential components of post-cesarean care, making Option D the correct answer.

2. A client newly prescribed sertraline is being taught by a nurse. Which statement by the client indicates understanding?

• A. I should take this medication with meals.
• B. I might have trouble sleeping when I start this medication.
• C. I should avoid drinking orange juice.
• D. I will feel better immediately after starting the medication.

Correct answer: B

Rationale: Choice B, 'I might have trouble sleeping when I start this medication,' indicates understanding because insomnia is a common side effect of sertraline, especially when initiating the medication. This statement shows the client comprehends a potential adverse effect and is prepared for it. Choices A, C, and D are incorrect. Taking sertraline with or without meals does not significantly affect its efficacy. There is no specific contraindication about drinking orange juice while on sertraline. Feeling better immediately after starting the medication is unlikely as sertraline usually takes some time to exert its therapeutic effects.

3. A nurse is providing discharge instructions to a client after a myocardial infarction. Which of the following should be included?

• A. Resume normal activities immediately
• B. Monitor for chest pain and report any recurrence
• C. Avoid all physical activity for 6 months
• D. Take medications only as needed

Correct answer: B

Rationale: The correct answer is B: 'Monitor for chest pain and report any recurrence.' After a myocardial infarction, it is crucial for clients to be vigilant about any signs of chest pain as it could indicate a recurrent event. Prompt reporting of chest pain can lead to timely intervention, preventing further complications. Choice A is incorrect because resuming normal activities immediately after a heart attack can be dangerous and is not recommended. Choice C is also incorrect as avoiding all physical activity for 6 months is excessive and can lead to deconditioning. Choice D is incorrect as medications prescribed after a myocardial infarction are usually meant to be taken regularly as prescribed, not just as needed.

4. A client with severe preeclampsia is receiving magnesium sulfate intravenously. Which action should the nurse take when toxicity occurs?

• A. Position the client supine
• B. Prepare an IV bolus of dextrose 5%
• C. Administer calcium gluconate IV
• D. Administer methylergonovine IM

Correct answer: C

Rationale: When toxicity from magnesium sulfate occurs, the nurse should administer calcium gluconate IV as it is the antidote for magnesium sulfate toxicity. Positioning the client supine may not address the toxicity issue. Administering dextrose 5% is not the appropriate intervention for magnesium sulfate toxicity. Methylergonovine is used to manage postpartum hemorrhage and is not indicated for magnesium sulfate toxicity.

5. A client had a pituitary tumor removed. Which of the following findings requires further assessment?

• A. Glasgow scale score of 15
• B. Blood drainage on dressing measuring 3 cm
• C. Report of dry mouth
• D. Urinary output greater than fluid intake

Correct answer: D

Rationale: The correct answer is D. Increased urinary output greater than fluid intake can indicate diabetes insipidus, a common complication after pituitary surgery. Diabetes insipidus is characterized by the excretion of a large volume of dilute urine, leading to dehydration and electrolyte imbalances. This finding requires immediate assessment and intervention. Choice A, a Glasgow scale score of 15, indicates normal neurological functioning. Choice B, blood drainage on dressing measuring 3 cm, may require monitoring but is not a priority over the potential complication of diabetes insipidus. Choice C, a report of dry mouth, is a common complaint postoperatively and can be managed with oral care measures.

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