Nursing Elites

1. A nurse is providing discharge teaching to a client who had a stroke. What instruction should the nurse provide?

• A. Avoid lifting more than 5 pounds.
• B. Perform range-of-motion exercises daily.
• C. Take medications at the same time every day.
• D. Monitor blood pressure daily.

Correct answer: C

Rationale: The correct answer is C: 'Take medications at the same time every day.' Consistency in medication administration is crucial for stroke recovery to maintain therapeutic drug levels in the body. Choice A, 'Avoid lifting more than 5 pounds,' though important to prevent strain, is not directly related to medication adherence. Choice B, 'Perform range-of-motion exercises daily,' is beneficial for overall recovery but is not specific to medication management. Choice D, 'Monitor blood pressure daily,' is important but does not address the key aspect of medication regimen adherence.

2. How should fluid balance in a patient with heart failure be monitored?

• A. Monitor daily weight
• B. Monitor input and output
• C. Check for edema
• D. Monitor blood pressure

Correct answer: A

Rationale: The correct answer is to monitor daily weight. Daily weight monitoring is crucial in assessing fluid balance in patients with heart failure because sudden weight gain can indicate fluid retention. Monitoring input and output (choice B) is important but may not provide a complete picture of fluid balance. Checking for edema (choice C) is a sign of fluid accumulation but may not be as accurate as daily weight monitoring. Monitoring blood pressure (choice D) is important in heart failure management but does not directly assess fluid balance.

3. A nurse is caring for a client in labor who is receiving electronic fetal monitoring. The nurse notes early decelerations. Which of the following should the nurse expect?

• A. Fetal hypoxia
• B. Abruptio placentae
• C. Post maturity
• D. Head compression

Correct answer: D

Rationale: When a nurse notes early decelerations in electronic fetal monitoring, it indicates head compression, which is generally considered benign and not associated with fetal hypoxia, abruptio placentae, or post maturity. Early decelerations mirror the uterine contractions and are a normal response to fetal head compression during labor.

4. A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should the nurse plan to take?

• A. Obtain the newborn's body temperature using a tympanic thermometer
• B. Pull the pinna of the infant's ear forward before inserting the probe
• C. Auscultate the newborn's apical pulse for 60 seconds
• D. Measure the newborn's head circumference over the eyebrows and below the occipital prominence

Correct answer: C

Rationale: The correct answer is C: Auscultate the newborn's apical pulse for 60 seconds. When assessing a newborn, it is essential to auscultate the apical pulse for a full 60 seconds to accurately determine their heart rate. This method allows for a more precise measurement, considering the variability in heart rates in newborns. Choice A is incorrect because tympanic thermometers are not typically used for newborns due to their ear canals being small and not fully developed. Choice B is incorrect as pulling the pinna forward is not necessary for assessing the apical pulse. Choice D is incorrect as measuring head circumference involves a different assessment and is not relevant to determining the heart rate of a newborn.

5. A client has a new prescription for metoprolol. Which of the following client statements indicates an understanding of the teaching?

• A. I will take this medication with a glass of milk.
• B. I will take my pulse before taking this medication.
• C. I will stop taking this medication if I experience nausea.
• D. I will take an antacid with this medication.

Correct answer: B

Rationale: The correct answer is B. Clients taking metoprolol should regularly check their pulse and should not take the medication if their pulse is too low. Option A is incorrect because metoprolol should not be taken with a glass of milk. Option C is incorrect because stopping medication abruptly can be harmful. Option D is incorrect because antacids should not be taken with metoprolol as they can decrease its absorption.

Similar Questions