Nursing Elites

1. A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian.

• A. A client who has a prescription for warfarin and states, 'I will need to limit how much spinach I eat.'
• B. A client who has gout and states, 'I can continue to eat anchovies on my pizza.'
• C. A client who has a prescription for spironolactone and states, 'I will reduce my intake of foods that contain potassium.'
• D. A client who has osteoporosis and states, 'I'll plan to take my calcium carbonate with a full glass of water.'

Correct answer: C

Rationale: The correct answer is C. Spironolactone is a potassium-sparing diuretic, which means it helps the body retain potassium and excrete sodium and water. Therefore, clients on spironolactone should reduce their intake of foods high in potassium to prevent hyperkalemia. Choices A, B, and D are incorrect because limiting spinach intake due to warfarin, eating anchovies with gout, and taking calcium carbonate with water for osteoporosis do not directly relate to the medication's side effects or dietary restrictions associated with spironolactone.

2. A client has a prescription for digoxin. Which of the following instructions should the nurse include?

• A. Take this medication with food.
• B. Avoid taking antacids at the same time as this medication.
• C. Take this medication if your heart rate is above 100/min.
• D. Notify your provider if you experience nausea or visual changes.

Correct answer: D

Rationale: The correct instruction the nurse should include for a client prescribed digoxin is to notify the provider if they experience nausea or visual changes, as these symptoms can indicate digoxin toxicity. Option A is incorrect because digoxin should be taken on an empty stomach for better absorption. Option B is incorrect as antacids can interfere with the absorption of digoxin. Option C is incorrect as taking digoxin based on heart rate alone is not appropriate.

3. A client in active labor requests pain management. Which of the following actions should the nurse take?

• A. Administer ondansetron.
• B. Place the client in a warm shower.
• C. Apply fundal pressure during contractions.
• D. Assist the client to a supine position.

Correct answer: B

Rationale: During active labor, nonpharmacologic comfort measures like placing the client in a warm shower are effective for pain relief. Ondansetron (Choice A) is an antiemetic and not used for pain management during labor. Applying fundal pressure (Choice C) can cause harm and is not recommended due to the risk of uterine rupture. Assisting the client to a supine position (Choice D) is not ideal in labor as it can decrease blood flow to the placenta and is associated with increased maternal complications.

4. A client is receiving radiation therapy to the head and neck. Which of the following interventions should the nurse include?

• A. Instruct the client to use an alcohol-free mouthwash.
• B. Apply heat packs to the radiation site.
• C. Provide a diet low in carbohydrates.
• D. Avoid exposure to direct sunlight during treatment.

Correct answer: D

Rationale: The correct intervention for a client receiving radiation therapy to the head and neck is to avoid exposure to direct sunlight. Direct sunlight should be avoided to protect the skin from further irritation and damage caused by the radiation therapy. Instructing the client to use an alcohol-free mouthwash is important to prevent irritation and maintain oral hygiene, making choice A incorrect. Applying heat packs to the radiation site is contraindicated as heat can further aggravate the skin, making choice B incorrect. Providing a diet low in carbohydrates is not directly related to radiation therapy to the head and neck, so choice C is also incorrect.

5. A nurse is assessing a client who is in active labor, and the FHR baseline has been 100/min for 15 minutes. What should the nurse suspect?

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

Correct answer: C

Rationale: The correct answer is C: Maternal hypoglycemia. Maternal hypoglycemia can lead to fetal bradycardia, which is indicated by a baseline FHR of 100/min. In this scenario, the sustained low baseline FHR suggests a possible link to maternal hypoglycemia. Maternal fever (Choice A) typically presents with tachycardia rather than bradycardia in the fetus. Fetal anemia (Choice B) usually causes fetal tachycardia as a compensatory mechanism to deliver more oxygen to tissues. Chorioamnionitis (Choice D) is associated with maternal fever and an elevated fetal heart rate, not a sustained low baseline FHR.

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